Secondary Prevention Of Coronary Artery Disease Research Articles

Elevated levels of plasma inactive stromal cell derived factor-1a predict long-term adverse outcomes in diabetic patients with coronary artery disease

Abstract Background Because of the significantly increased cardiovascular risk by complicating type 2 diabetes (T2D) in patients with coronary artery disease (CAD), the appropriate risk estimation is crucial in patients with T2D following percutaneous coronary intervention (PCI). Nevertheless, there is no established biomarker which can precisely predict outcomes in this particular population. Although stromal cell derived factor-1α (SDF-1α) has been suggested to play a key role in the pathogenesis of T2D, the prognostic impact of SDF-1α in the secondary prevention of CAD is yet to be elucidated. In particular, the ability of SDF-1α isoforms in outcome prediction in this population has not been assessed. Purpose The aim of present study was to investigate the prognostic implication of three isoforms of SDF-1α, such as total, active, and inactive forms of SDF-1α in diabetic patients following PCI. Methods This single-center retrospective analysis involved consecutive patients with T2D who underwent PCI for the first time between 2008 and 2018 (n=849). Primary and secondary outcome measures were all-cause death and the composite of cardiovascular death, non-fatal myocardial infarction, and ischemic stroke (3P-MACE), respectively. For determining plasma levels of SDF-1α, we measured not only total, but also the active type of SDF-1α by ELISA. Inactive isoform of the SDF-1α was calculated by subtracting the active isoform from total SDF-1α. Participants were divided into two groups according to the median of three forms of plasma SDF-1α levels (total SDF-1α: 2270 pg/mL, active SDF-1α: 686 pg/mL, inactive SDF-1α: 1537 pg/mL) at PCI procedure and the incidence and risk of subsequent endpoints following PCI were assessed. Results Kaplan-Meier analyses revealed increased risk of both all-cause death and 3P-MACE in patients with elevated levels of inactive SDF-1α (Figure 1). Constantly, multivariate Cox hazard analyses adjusted by age, sex, body mass index (>25), acute coronary syndrome, and chronic kidney disease (≥ stage 3) repeatedly indicated the 1 higher log-transformed inactive SDF-1α was significantly associated with increased risk of all-cause death (hazard ratio (HR): 2.21, 95% confidence interval (CI): 1.05–4.67, p=0.04) and 3P-MACE (HR: 2.30, 95% CI: 1.01–5.09, p=0.04). However, neither of total and active SDF-1α reached statistical significance (Figure 2). Furthermore, the addition of inactive SDF-1α to baseline models in multivariate Cox proportional hazard analysis significantly enhanced both the net reclassification improvement (NRI) and the integrated discrimination improvement (IDI) for all-cause death (NRI 0.29, p=0.009; IDI 0.007, p=0.03) and 3P-MACE (NRI 0.38, p=0.001; IDI 0.007, p=0.01) while adding total and active SDF-1α did not improve them. Conclusion In diabetic patients following PCI, elevated levels of plasma inactive SDF-1α, not total and active isoforms, might be a useful indicator of adverse outcomes.

Association of metabolic phenotypes with cardiovascular events in primary and secondary prevention

Abstract Background Metabolic disorders are established risk factors for the development of coronary artery disease (CAD) and major adverse cardiovascular events (MACE). Although obesity is strongly related with the metabolic health status, its role as a cardiovascular risk modifier in the absence of metabolic disorders remains controversial. Recent implementation of nutrient-stimulated hormone-based therapies (NUSH) including glucagon-like peptide-1 (GLP-1) receptor agonists in the treatment of obesity even in metabolically healthy individuals requires further understanding to ensure optimal patient management. Purpose The aim of this study is to investigate the association of metabolic phenotypes with cardiovascular events in primary and secondary prevention of CAD. Methods We included patients over 18 years electively evaluated for CAD by invasive coronary angiography (ICA) between 2010 and 2021 in our tertiary referral centre in one of Europe’s largest university hospitals. Metabolic disorder was considered as the presence of diabetes, irrespective of additional risk factors, or hypertension and hyperlipidaemia, and obesity as a BMI of ≥30 kg/m², distinguishing four metabolic phenotypes: metabolically healthy/unhealthy nonobese/obese (MHN, MHO, MUN, MUO). The primary study endpoint MACE was defined as a composite of cardiovascular death, non-fatal myocardial infarction, ischemic stroke, and hospitalization for heart failure. Results The total study population included 12 760 patients (68 [58-76] years; 57.3% male), of whom 56.5% presented metabolically healthy (43.3% MHN; 13.1% MHO) and 43.5% unhealthy (28.3% MUN; 15.2% MUO). During a median follow up time of 3.91 (1.75-7.09) years, 2 592 (20.3%) MACE and 3 351 (26.3%) all-cause deaths occurred. Cox regression analysis adjusted for age, sex, and chronic kidney disease (CKD) showed different risk patterns for distinct metabolic phenotypes (Table 1). While we observed higher event rates in metabolically unhealthy compared to healthy individuals, obesity alone was not associated with increased events (Figure 1). However, metabolically healthy individuals experienced lower event rates with increasing BMI. Among patients without or with nonobstructive CAD, metabolic disease was strongly associated with increased subsequent coronary revascularization regardless of BMI. These patterns were similar across all endpoints irrespective of presence of obstructive or nonobstructive CAD. Conclusions Whereas metabolic disorders are strongly associated with adverse clinical events, obesity alone does not reflect the cardiovascular risk profile in patients with or without obstructive CAD. Thus, focusing on obesity alone for primary or secondary prevention appears unjustified. Particularly after the recent implementation of GLP-1 receptor agonists for the treatment of obesity, precise and individual risk stratification is essential to allow for an optimal personalized patient management.Figure 1Table 1

Impact of measured or calculated small dense LDL cholesterol compared with apolipoprotein B or non-HDL cholesterol for long-term secondary prevention in patients with stable coronary artery disease

Abstract Background This study was aimed to investigate whether directly measured small dense low-density lipoprotein cholesterol (D-sdLDL-C) can predict long-term coronary artery disease (CAD) events compared with LDL-C, non–high-density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (apoB), and estimated sdLDL-C (E-sdLDL-C) determined by Sampson’s equation in patients with stable CAD. Methods D-sdLDL-C measured at Showa University, and E-sdLDL-C were evaluated in 790 male and 244 female patients with stable CAD. CAD events defined as sudden cardiac death, onset of acute coronary syndrome, and/or need for coronary revascularization were monitored for 12 years. Cut-points of D-sdLDL-C, E-sdLDL-C, LDL-C, non-HDL-C, and apoB were determined by receiver operating characteristic curves. Results CAD events were observed in 238 male and 67 female patients. The Kaplan–Meier event-free survival curves showed that patients with D-sdLDL-C ≥32.1 mg/dL had an increased risk for CAD events (chi-square from log-rank test = 7.23), whereas risk in patients with E-sdLDL-C ≥36.2 mg/dL was not. In the group with high D-sdLDL-C, the multivariable-adjusted hazard ratio (HR) was 1.47, 95% confidence interval (CI) 1.15-1.89, and it remained significant after adjustment for LDL-C, non-HDL-C, or apoB. These results remained significant in the patients treated with statin. HRs for high LDL-C, non-HDL-C, or apoB were not statistically significant after adjustment for high D-sdLDL-C. The high D-sdLDL-C enhanced risk of high LDL-C, non-HDL-C, and apoB (HR 1.73, 95%CI 1.27-2.37). Conclusions: High D-sdLDL-C can predict long-term recurrence of CAD in stable CAD patients independently of apoB and non-HDL-C by distinguishing the patients at high risk. D-sdLDL-C is an independent risk-enhancer for secondary CAD prevention whereas E-sdLDL-C is not.Figure

Role of bile acids in atherogenesis: review

The review describes the metabolism of bile acids (BAs) in the human body, their effect on cholesterol metabolism and the development of atherosclerosis, which remains one of the most pressing problems in medicine. The problem of cholestasis is discussed, which is often found in patients with cardiovascular diseases with comorbidities, including non-alcoholic fatty liver disease and which plays a key role in the development of many complications associated with impaired BA metabolism, including hyperlipidemia, metabolic syndrome. Cholestasis treatment, which allows restoring normal cholesterol levels, are considered. Timely administration of ursodeoxycholic acid makes it possible to prevent atherosclerosis (primary prevention of atherosclerosis), because with normal bile metabolism, the levels of proatherogenic lipids are normalized and the production of inflammatory mediators, high levels of which contribute to atherogenesis, decreases. In this review, the author presents the important role of bile metabolism in the primary and secondary prevention of atherosclerosis and the possibility of solving this issue by prescribing ursodeoxycholic acid and changing lifestyle.

Cardiac rehabilitation for patients with coronary artery disease

Background: Coronary artery disease (CAD) is the leading cause of death in Korea, with high rates of recurrence and mortality associated with relapse. Therefore, various strategies are required to prevent recurrent CAD. Cardiac rehabilitation (CR) is proven to be safe and highly effective and is therefore considered essential treatment for secondary prevention of CAD. CR is reimbursed in Korea since February 2017.Current Concepts: CR comprises the following main components: education, evaluation, and treatment. CR education includes increasing awareness regarding the chronic risk factors associated with CAD and motivating patients to manage these factors independently. Such management includes smoking cessation, moderation in alcohol consumption, weight management, maintenance of physical activity, medication adherence, and psychosocial interventions. CR evaluation through cardiopulmonary exercise tests is useful to predict prognosis and provides basic information for exercise prescriptions. CR treatment includes prescription of a personalized exercise program, with aerobic exercise as the main component supported by resistance training.Discussion and Conclusion: CR is an important treatment modality that significantly improves exercise capacity while reducing readmission rates and mortality in patients with CAD . Therefore, it is essential to understand CR methods and concepts and encourage patients with CAD to participate in CR programs.

Behavioral, Clinical, and Coronary Artery Calcium Screening for Prevention and Treatment of Subclinical Atherosclerosis: Implications for Health Education

ABSTRACT Background In the USA, heart disease is the leading cause of death for women and men. Coronary artery disease (CAD) is the most common type of heart disease. Purpose To investigate the association between behavioral and non-behavioral risk factors associated with subclinical atherosclerosis. Methods Patients referred for a CT angiography completed a demographic/behavioral questionnaire and medical history interview for CAD risk factors. Risk factor data were correlated with CAD subclinical atherosclerosis scores for 521 participants. Results Frequency among four levels of CAD revealed: no disease 38%, mild atherosclerotic 20%, moderate atherosclerotic 30%, and severe atherosclerosis 12%. Significant (p ≤ .05) demographic variables were as follows: age, race, marital status, and employment status. Significant predictive behavioral variables were as follows: tobacco use, daily water intake, sodium consumption, exercise days per week, and junk food consumption. Risk factors significantly associated with subclinical CAD included hypertension, diabetes, sleep apnea, and abnormal coronary calcium score. Discussion Multi-slice CT angiography allows early reliable evaluation of subclinical atherosclerosis and correlation with behavioral/non-behavioral risk factors with level of CAD, instrumental to primary and secondary CAD prevention, limiting tertiary CAD treatment. Translation to Health Education Practice Study results have implications for Health Educators with regard to intervention research planning, implementation, and evaluation.

Impact of Direct Measurement of Small Dense Low-Density Lipoprotein Cholesterol for Long-Term Secondary Prevention in Patients with Stable Coronary Artery Disease.

This study investigated whether directly measured small dense low-density lipoprotein cholesterol (D-sdLDL-C) can predict long-term coronary artery disease (CAD) events compared with low-density lipoprotein cholesterol (LDL-C), non-high-density lipoprotein cholesterol (non-HDL-C), apolipoprotein B (apoB), and estimated small dense low-density lipoprotein cholesterol (E-sdLDL-C) determined by the Sampson equation in patients with stable CAD. D-sdLDL-C measured at Showa University between 2010 and 2022, and E-sdLDL-C were evaluated in 790 male and 244 female patients with stable CAD. CAD events, defined as sudden cardiac death, onset of acute coronary syndrome, and/or need for coronary revascularization, were monitored for 12 years. Cutoff lipid levels were determined by receiver operating characteristic curves. CAD events were observed in 238 male and 67 female patients. The Kaplan-Meier event-free survival curves showed that patients with D-sdLDL-C ≥32.1 mg/dL (0.83 mmol/L) had an increased risk for CAD events (P = 0.007), whereas risk in patients with E-sdLDL-C ≥36.2 mg/dL (0.94 mmol/L) was not increased. In the group with high D-sdLDL-C, the multivariable-adjusted hazard ratio (HR) was 1.47 (95% CI, 1.15-1.89), and it remained significant after adjustment for LDL-C, non-HDL-C, or apoB and in patients treated with statins. HRs for high LDL-C, non-HDL-C, or apoB were not statistically significant after adjustment for high D-sdLDL-C. Higher D-sdLDL-C was associated with enhanced risk of high LDL-C, non-HDL-C, and apoB (HR 1.73; 95% CI, 1.27-2.37). Higher D-sdLDL-C can predict long-term recurrence of CAD in stable CAD patients independently of apoB and non-HDL-C. D-sdLDL-C is an independent risk enhancer for secondary CAD prevention, whereas E-sdLDL-C is not.UMIN-CTR Clinical Trial Number: UMIN000027504.

Opportunities to Improve Health Economic Outcomes in Coronary Artery Disease: A Review of Care Pathways in the United States Healthcare System

Background: Despite medical advances, coronary artery disease remains the leading cause of death worldwide. Evidence suggests that current uptake and efficacy of strategies in coronary care are suboptimal. This review aimed to investigate key areas for improvements in coronary care in the United States, and to estimate the potential health gains if existing strategies were improved. Methods: A targeted literature review of the acute and chronic coronary artery disease care pathways was conducted to identify areas where health outcomes could be improved in the United States if uptake or efficacy of existing strategies were optimal. Using hypothetical scenarios of maximally improved efficacy or uptake from published literature and health impact modeling, we calculated potential additional lives saved and potential reductions in direct medical costs, using Medicare rates as proxy, if improvements were realized. Results: We identified the following areas where improvements in uptake or efficacy of existing strategies could positively impact coronary artery disease outcomes in the United States: primary prevention, early detection, efficient diagnosis, reducing time to reperfusion, and secondary prevention. Improvements in primary and secondary coronary artery disease prevention have the potential to reduce annual direct medical costs by approximately $17 billion USD and $5 billion USD, respectively. Further, if the efficacy of existing preventive strategies was improved to 80%, then 102,000 (primary prevention) and 32,000 (secondary prevention) lives could be saved annually. Improvements in early detection, more efficient diagnosis, and reducing time to reperfusion could also substantially increase lives saved by increasing the uptake and efficacy of timelier percutaneous interventions, and potentially reduce annual direct medical costs by $1 billion USD. Conclusions: Improvements in primary prevention offer the greatest potential for lives saved and medical costs avoided. Future innovations should focus on advancing existing primary preventive strategies, while simultaneously driving innovation towards developing effective novel strategies in each of the key areas for improvement.

Proportion of ischemic and nonischemic sudden cardiac death by age and sex

Abstract Background Among women the incidence of sudden cardiac death (SCD) is significant, but lower than in men. During the last decades the proportion of nonischemic SCD seems to have increased in both sexes. Coronary artery disease (CAD) have changed to be sickness of elderly women rather than middle-aged men as in women the prevalence and incidence of CAD starts to increase after the menopause. Purpose The aim of this study was to illustrate how the amount and the proportions of ischemic and nonischemic SCD vary between women and men in different age groups. Methods The Fingesture study has systematically collected clinical and autopsy data from SCD victims in Northern Finland between 1998 and 2017. The cohort consists of 5,869 SCD victims. Results Approximately one fifth of the SCD victims were women (21.1%; P<0.001). Three out of four SCDs were ischemic (74.8%; P<0.001) and majority of the ischemic SCD victims were men (79.8%; P=0.005). The mean age of female victims was 70.1±13.1 years and 63.5±11.8 years among male victims (P<0.001). Amongst women one SCD out of 15 occurred to the subject under 50 years of age (6.7%; P<0.001) whereas in men one SCD victim out of nine was under 50 years old (11.4%; P<0.001). A nonischemic SCD was observed in 350 women and in 1,127 men (P<0.001). The proportion of nonischemic death was higher among women than in men in every age group from under 30 years of age to subjects of 84 years old studied in five year periods (Figure 1). Only age group of 65-69 years in women and 60-64 years in men were not statistically significant, otherwise all the P-values were ≤0.003. The difference in proportion of ischemic and non-ischemic SCD was the smallest among subjects of 40-49 years of age amongst the proportion of ischemic SCD increased rapidly both in women and in men as the prevalence of non-ischemic SCD started to decrease (Figure 1). Amongst SCD victims aged 40-44 years 47.9% of the deaths of men (P<0.001) and 41.7% of the deaths of women (P<0.001) were ischemic etiology. Among women aged 50-54 years over half of the SCDs were ischemic (53.1%; P<0.001). The gender difference in proportion of ischemic SCD was actually the smallest in age groups 40-49 years and after 70 years of age, and its largest in the middle in favor of men. (Figure 1). After the age of 70 years the total amount of SCDs started to plateau in men and decrease in the amount of SCDs was seen in men after the age of 75 years as in women the plateau phase was not reached until the age of 80 years (Figure 2). Conclusion Minority of the SCDs occur under the age of 50 years, especially among women. The proportion of nonischemic SCD was higher in women than in men despite the age. However, already in pre- and perimenopausal age the proportion of ischemic SCD in women was remarkable and the amount of ischemic SCD increased until the age of 80 years emphasizing the need of early primary and secondary prevention of CAD also in women not only in men.Figure 1.Figure 2.

Cardiovascular and inflammatory biomarkers for non-invasive detection of coronary artery obstruction and prediction of long-term survival in patients with suspected chronic coronary syndrome

Abstract Introduction and methods: The knowledge about diagnostic and prognostic value of cardiac and inflammatory biomarkers in patients with chronic coronary syndrome (CCS) is limited. To address this, we analyzed serum levels of selected biomarkers in 2536 patients with suspected CCS (35% female) from the Leipzig LIFE Heart Study who were admitted for coronary angiography. The median follow-up was 10 years. The following biomarkers were considered: high sensitive troponin T (hsTNT), N-terminal pro B-type natriuretic peptide (NT-proBNP), copeptin, high sensitive C-reactive protein (hsCRP) and interleukin-6 (IL-6). Patients were stratified according to the angiographic severity of coronary artery disease (CAD): CAD0 (no sclerosis), CAD1 (non-obstructive, i.e., stenosis < 50%), CAD2 (≥ one stenosis ≥ 50%). Group comparison (GC) included GC1: CAD0 + 1 vs. CAD2, GC2: CAD0 vs. CAD1 + 2. Using age-, sex and symptom-based pre-test probability (PTP) table for obstructive CAD (i.e. CAD 2) which was published in the current CCS guidelines, patients were further classified into the following three categories: PTP < 5% (n=559), PTP 5-15% (n=545) and PTP > 15% (n=1432). Results CAD0, CAD1, CAD2 were apparent in 999, 529, and 1008 patients, respectively. Upon adjustment for traditional risk factors (TRF) the levels of hsTNT, NT-proBNP and IL-6 showed significant difference in GC1 (hsTNT: p=2.0x10-10, NT-proBNP: p=0.049, IL6: p=0.030). In GC2 only elevated hsTNT remained significant (p=1.9x10-7). In the ROC analysis only hsTNT slightly improved the AUC for the GC1-comparison in addition to TRF (0.729 with vs 0.712 witt hsTNT, p=0.013). Within the PTP subcategories the following results were obtained: PTP < 5%: AUC 0.747 with vs 0.730 without hsTNT, p=0.017; PTP 5-15 %: AUC 0.636 with vs 0.670 without hsTNT, p<0.001; PTP > 15%: AUC 0.699 with vs 0.677 without hsTNT, p= 0.024). In PTP 5-15% subgroup TropT cut-off value < 3 pg/mL (N= 119 / 23.4%) showed sensitivity of 89.7% and specificity of 73.1% for CAD2 detection. Ten years survival in groups CAD0, CAD1, CAD2 were 88.3%, 77.3%, 72.4%, respectively. In the multivariate analysis elevated hsTNT, NT-proBNP, copeptin and IL-6 remained significant mortality predictors in CAD2 patients with hazard ratios of similar magnitude (i.e. 1.5, 1.3, 1.4 and 1.3 per unit on the log-scale of the parameters, respectively). hsCRP did not reach significance. In the model stratified into tertiles according to the effects of classical risk factors and the joint biomarker levels for except hsCRP, hazard rates were 3.13 (tertile 2 vs 1) and 11.2 (tertile 3 vs 1). Conclusions In the present study hsTNT substantially improved the detection of obstructive CAD particularly in patients with intermediate PTP 5-15%. Furthermore, the studied biomarkers enable fast and precise non-invasive prediction of mortality risk in patients with suspected CCS, allowing tailored primary and secondary CAD prevention in this high-risk group.

Abstract 14196: Prevalence of Ischemic and Nonischemic Sudden Cardiac Death Differs by Sex and Age

Introduction: During the last decades the proportion of nonischemic sudden cardiac death (NI-SCD) seems to have increased in both sexes. In women the incidence of coronary artery disease (CAD) starts to increase after the menopause. Aim: The aim of this study was to illustrate how the amount and the proportions of ischemic SCD (I-SCD) and NI-SCD vary between women and men in different age groups. Methods: The Fingesture study consists systemically collected clinical and autopsy data of 5,869 SCD victims of Northern of Finland (21% women). Results: In women 6.7% of the SCDs occurred at the age < 50 years and in men 11.4% (P<0.001 for both). I-SCDs covered 75% (P<0.001) of the cases of which 80% were men (P=0.005). The proportion of NI-SCDs was higher in women in every age group. Proportion of I-SCDs started to increase rapidly in both sexes at the age of 40-44 years. In women aged 50-54 years 53% of the cases were I-SCDs. The gender difference in proportion of I-SCD was actually the smallest in age groups 40-49 years and after 70 years of age, and its largest in the middle in favor of men. (Figure 1). After the age of 70 years the total amount of SCDs started to plateau in men and decrease in the amount of SCDs was seen in men after the age of 75 years as in women the plateau phase was not reached until the age of 80 years (Figure 2). Conclusions: Minority of the SCDs occur under the age of 50 years, especially in women. The proportion of NI-SCD was higher in women than in men despite the age but the proportion of I-SCD was remarkable already at pre- and perimenopausal age. The amount of I-SCD increased in women until the age of 80 years emphasizing the need of early primary and secondary prevention of CAD also in women not only in men.

Abstract 15377: Traditional Cardiovascular Risk Factors Do Not Fully Explain the Risk of CAD Population in Colombia

Introduction: Major cardiovascular events occur even having reached LDL-C goals. Tolima department has the highest rate of cardiovascular mortality within Colombia. Hypothesis: in patients who underwent percutaneous coronary intervention (PCI) in a healthcare institution in Ibague Colombia, there is an increasing cardiovascular risk regardless of traditional risk factors. Methods: Descriptive, retrospective analysis of a cohort of patients with coronary artery disease (CAD) with PCI between 2020-2023. A multiple logistic regression model was developed, adjusted for predictors of CAD (Figure 1). Data was analyzed through R-4.3.0, JASP0.17.1 and Python3.11. Results: A sample size of 463 patients who underwent PCI was assessed (Table 1). Dyslipidemia was the most prevalent risk factor 43.2%(n=200). Mean LDL-C was 102, mean HDL was 38 and mean triglycerides was 186. The most incident coronary heart disease was NSTEMI 50.5%(n=234). Data was fitted into a logistic regression model accounting for comorbidities, risk factors and lipid profile values. Regression coefficients computed for CAD were around 0.07. Independent variables explain approximately 7 up to 16.1% of the variance observed in the dependent variable (Figure 1). Conclusions: In primary and secondary prevention for CAD, there is a high prevalence of risk factors. Although risk factors impact the outcome, they account for a relatively little variability within the model. Results imply that there are other key factors that contribute to the outcome and may not be measured currently. Further studies must be developed to evaluate markers in residual risk that may have an impact on the prognosis of patients with CAD.

Healthcare professionals’ perceptions of using a digital patient educational programme as part of cardiac rehabilitation in patients with coronary artery disease – a qualitative study

BackgroundParticipation in cardiac rehabilitation in patients with coronary artery disease (CAD) remains underutilised. Digital educational programmes, as part of cardiac rehabilitation, are emerging as a means of increasing accessibility, but healthcare professionals’ perceptions of implementing and using these programmes are not known. The aim of the study was therefore to explore healthcare professionals ̓ perceptions and experiences of implementing and using a digital patient educational programme (DPE) as part of cardiac rehabilitation after acute CAD.MethodsIndividual semi-structured interviews were performed with 12 nurses and physiotherapists, ten women with a median age of 49.5 (min 37- max 59) years, with experience of using the DPE as part of a phase II cardiac rehabilitation programme in Region Västra Götaland, Sweden. The interviews were transcribed verbatim and analysed with inductive content analysis according to Graneheim and Lundman.ResultsAn overall theme was identified throughout the unit of analysis: “Digital patient education – a complement yet not a replacement”. Within this theme, three main categories were identified: “Finding ways that make implementation work”, “Accessibility to information for confident and involved patients” and “Reaching one another in a digital world”. Each main category contains a number of sub-categories.ConclusionsThis study adds new knowledge on healthcare professionals’ perceptions of a digital patient educational programme as a valuable and accessible alternative to centre-based education programmes as part of cardiac rehabilitation for patients with CAD. The participants highlighted the factors necessary for a successful implementation, such as support through the process and sufficient time from the employer to learn the system and to create new routines in daily practice. Future research is needed to further understand the impact of digital education systems in the secondary prevention of CAD. Ultimately, hybrid models, where the choice of delivery depends on the preferences of the individual patient, would be the optimal model of care for the future.

Cholesterol Paradox in Older People with Type 2 Diabetes Mellitus Regardless of Lipid-Lowering Drug Use: A Cross-Sectional Cohort Study.

Lipid-lowering drugs (LLDs) have protective effects against coronary artery disease (CAD) and cerebrovascular disease (CVD); however, a paradoxical association with cholesterol has been identified in several diseases, such as diabetes, dementia, and atrial fibrillation. We aimed to analyze the association between LLDs and cholesterol levels in older adults with type 2 diabetes mellitus (T2DM). This cross-sectional study enrolled consecutive patients aged ≥50 years from three centers in Taiwan. A multiple logistic regression model was used, and odds ratios (ORs) for different levels of total cholesterol (TC) or low-density-lipoprotein cholesterol (LDL-C) compared with the highest level were adjusted for age, triglyceride level, sex, comorbidities, and medications. Among the 3688 participants, 572 with and 676 without T2DM used LLDs. After adjusting for age and sex, the non-T2DM group demonstrated better medical conditions, cognition, and daily function than the T2DM group, regardless of LLD use. Compared to the highest TC level (≥240 mg/dL), ORs were significantly increased as TC levels decreased. A similar pattern of T2DM prevalence was observed in LDL-C levels. Older people with T2DM demonstrated low cognitive and daily functions. Significantly reduced TC and LDL levels were associated with a higher T2DM prevalence in older adults regardless of LLD use. T2DM was associated with impaired cognitive and daily functioning. A higher prevalence of T2DM in older people with low cholesterol levels raises doubt surrounding cognition and daily function being jeopardized when the "lower is better" strategy is applied for the secondary prevention of CAD or CVD.

Designing a Multilevel Strategy to Enhance Secondary Prevention of Heart Disease.

Background Coronary artery calcification (CAC), the presence and severity of which strongly predict underlying coronary artery disease (CAD), can be seen on dedicated cardiac imaging studies or incidentally on noncardiac ones; however, the latter findings are commonly managed by primary care clinicians without clear accompanying recommendations and may represent an underrecognized opportunity to optimize secondary prevention of CAD. Methods Standardized practice guidelines and a multilevel implementation strategy for improving secondary prevention of cardiovascular disease through incidentally identified CAC were developed by an interdisciplinary committee. Evidence-based implementation strategies were selected1 and included integrating practice guidelines into radiology reports within the electronic medical records. Outpatient noncardiac computerized tomography scans performed before and after this initiative were retrospectively reviewed to evaluate changes in statin prescribing. Results Authors demonstrated an increase in the percentage of patients with mild CAC prescribed a statin and an increase in the percentage of patients with severe CAC prescribed a high-intensity statin after implementation of standardized practice guidelines and evidence-based implementation strategies. Conclusion Incidental CAC identification is common, particularly in those without known CAD. A multilevel implementation strategy and use of standardized practice guidelines appeared to improve provider prescribing behavior in the primary care setting and may provide an opportunity to enhance secondary CAC prevention.

Diagnosis and Treatment of Lower Extremity Arterial Disease-A Survey among Family Medicine Trainees in Poland.

Guidelines point to the ankle-brachial index (ABI) as a non-invasive tool for the initial diagnosis of lower extremity artery disease (LEAD). Questions have been raised whether primary practices should perform ABI. An online questionnaire was distributed among family medicine trainees in two academic centers in Poland. The questionnaire aimed to establish their knowledge about LEAD management and their opinion on the usefulness of ABI measurement and other LEAD diagnostic methods in primary care. ABI measurement was found either very or moderately useful in LEAD diagnosis by 94.5% of the respondents. Among the three most important elements of LEAD management, lifestyle changes, secondary prevention of atherosclerosis and exercise treatment were chosen, respectively, by 98.6%, 83.6% and 72.6% of them. ABI was seen as a useful diagnostic method at the primary care by 74% of the participants; however, 82.2% of them do not have access to ABI measurement in their workplace. The residents have good knowledge of the diagnostic methods of LEAD and consider ABI measurement as useful in LEAD diagnosis. However, most of them do not have access to ABI measurements in their clinical practices. Future discussion and potential financial changes will be needed for the introduction of ABI measurements into Polish primary care.

Impact of the eicosapentaenoic acid to arachidonic acid ratio on plaque characteristics in statin-treated patients with coronary artery disease

BackgroundA low eicosapentaenoic acid (EPA)/arachidonic acid (AA) ratio is associated with an increased risk of cardiovascular events in patients with coronary artery disease (CAD). ObjectiveTo clarify the impact of the EPA/AA ratio on the characteristics of non-culprit coronary plaques in statin-treated patients with CAD. MethodsA total of 370 consecutive stable coronary disease patients treated with statins, who underwent percutaneous coronary intervention for the culprit lesion and optical coherence tomography (OCT) imaging of the non-culprit plaque in a culprit vessel were included. The characteristics of non-culprit plaques assessed using OCT were compared between the lower EPA/AA group (EPA/AA <0.4, n = 255) and the higher EPA/AA group (EPA/AA ≥0.4, n = 115). ResultsThe prevalence of lipid-rich plaque (58.8 vs. 41.7%, p = 0.003) and plaque with macrophages (56.5 vs. 31.3%, p <0.001) was significantly higher in the lower EPA/AA group than in the higher EPA/AA group. This association was observed even if the LDL-C level was <100 mg/dL. The prevalence of thin-cap fibroatheroma was significantly higher in patients with lower EPA/AA and higher LDL-C (≥100 mg/dL) than in those with higher EPA/AA and lower LDL-C (<100 mg/dL) (odds ratio: 2.750, 95% confidence interval: 1.182-6.988, p = 0.024). An EPA/AA <0.4 was independently associated with a higher prevalence of lipid-rich plaque, plaque with macrophages, and cholesterol crystals. ConclusionLower EPA/AA ratio was associated with higher prevalence of vulnerable characteristics in non-culprit plaques. The present results suggest the importance of EPA/AA ratio on the secondary prevention of CAD.

Increased endothelin-1 levels in coronary artery disease with diabetes mellitus in an Indonesian population.

Diabetes mellitus (DM) increases risk of coronary artery disease (CAD). Endothelin-1 (ET-1) is a potential biomarker of endothelial dysfunction. This study aimed to evaluate ET-1 level in CAD patients and its relationship with DM. The cross-sectional design included subjects with angiographically proven CAD and controls among Indonesian. DM was defined by medical history and anti-diabetics use. Serum ET-1 level was measured in both subject groups. We recruited 305 subjects, 183 CAD patients and 122 controls. CAD subjects had higher percentage of males, DM, hypertension, dyslipidemia, smoking, family history of cardiovascular disease, and obesity. ET-1 level was significantly higher in CAD than in controls (2.44 ± 1.49 pg/mL vs. 1.76 ± 0.83 pg/mL; p < 0.001). Increased ET-1 level was significantly associated with DM and dyslipidemia. The highest ET-1 level was observed in CAD with DM, followed by CAD non-DM (2.79 ± 1.63 pg/mL vs. 2.29 ± 1.40 pg/mL; p = 0.023). Among controls, ET-1 level was the lowest in non-DM subjects. Female CAD had higher proportion of DM; however, ET-1 level was similar to male CAD with DM. In conclusion, an increased ET-1 level was significantly associated with DM in patients with CAD. Further research should investigate the potential role of ET-1 receptor antagonists in the secondary prevention of CAD with DM.

Biomarkers for Non-Invasive Stratification of Coronary Artery Disease and Prognostic Impact on Long-Term Survival in Patients with Stable Coronary Heart Disease.

Knowledge about cardiac and inflammatory biomarkers in patients with stable coronary artery disease (CAD) is limited. To address this, we analyzed 3072 patients (36% female) with a median follow-up of 10 years in the Leipzig LIFE Heart Study with suspected CAD with coronary angiography. Selected biomarkers included troponin T (hsTNT), N-terminal pro B-type natriuretic peptide (NT-proBNP), copeptin, C-reactive protein (hsCRP), and interleukin-6 (IL-6). Patients were stratified by CAD severity: CAD0 (no sclerosis), CAD1 (non-obstructive, i.e., stenosis < 50%), and CAD2 (≥one stenosis ≥ 50%). Group comparison (GC) included GC1: CAD0 + 1 vs. CAD2; GC2: CAD0 vs. CAD1 + 2. CAD0, CAD1, and CAD2 were apparent in 1271, 631, and 1170 patients, respectively. Adjusted for classical risk factors, hs-cTnT, NT-proBNP, and IL-6 differed significantly in both GC and hsCRP only in GC2. After multivariate analysis, hs-cTnT, NT-proBNP, and IL-6 remained significant in GC1. In GC2, hs-cTnT (p < 0.001) and copeptin (p = 0.014) reached significance. Ten-year survival in groups CAD0, CAD1, and CAD2 was 88.3%, 77.3%, and 72.4%. Incorporation of hs-cTnT, NT-proBNP, copeptin, and IL-6 improved risk prediction (p < 0.001). The studied cardiac and inflammatory biomarkers enable fast and precise non-invasive identification of mortality risk in CAD patients, allowing the tailoring of primary and secondary CAD prevention.

Assessment of Clinical Features in HIV-Infected Patients with Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention in China.

Objectives We aimed to compare coronary risk factors, burden of coronary artery disease (CAD), and 1-year prognosis of people living with HIV (PLWH) and HIV-negative controls who underwent percutaneous coronary intervention (PCI) for acute coronary syndromes (ACSs). Background Cardiovascular disease is drawing more and more attention in PLWH since effective antiretroviral therapy (ART) has been available. Clinical characteristics and outcomes of PLWH undergoing PCI for ACS in China remain unknown. Methods We compared demographic characteristics, angiographic features, and 1-year outcomes of 48 PLWH versus 48 HIV-negative controls matched for age (±2 years), sex, diabetes mellitus, and year of PCI (±2 years) in Beijing Ditan Hospital, Capital Medical University from January 2008 to November 2020. Results In PLWH (mean age: 53.6 ± 10.6 years, 95.8% male, and 79.2% on ART), high-density lipoprotein cholesterol was lower than in HIV-negative controls; however, the statin use was more common, the incidence of hypertension was lower, and low-density lipoprotein cholesterol, and the body mass index were significantly lower than in controls. Two groups had a similar extent of coronary atherosclerosis as measured by the presence of multivessel diseases and the median Gensini score; however, lesions of PLWH were longer and were more likely to locate at the proximal segment of the coronary artery. In addition, the risk of major adverse cardiac and cerebrovascular events at 1 year was similar in both groups. Conclusion PLWH undergoing PCI displayed similar CAD burden and 1-year prognosis compared with HIV-negative patients. Early detection of cardiovascular risk factors and appropriate secondary prevention of CAD in PLWH might alleviate the risk of severe adverse cardiovascular events.