Secondary Prevention Strategies Research Articles

Lipid-lowering therapy in patients with coronary heart disease: an Italian real-life survey. Results from the Survey on Risk FactOrs and CardiovascuLar secondary prEvention and drug strategieS (SOFOCLES) in Italy.

In patients at high cardiovascular risk, a low-density lipoprotein cholesterol (LDL-C) reduction of ≥50% from baseline and an LDL-C goal of <70 mg/dL (or <55 mg/dL in very high-risk patients) are recommended. Multiple registry and retrospective studies have shown that patients with high atherosclerotic cardiovascular risk often do not reach the targets defined by the European Society of Cardiology guidelines as a result of suboptimal management of LDL-C. Here, we report the data on lipid-lowering therapy and lipid targets from the Survey on Risk FactOrs and CardiovascuLar secondary prEvention and drug strategieS (SOFOCLES), an observational, prospective study designed to collect data on patients with ischemic heart disease treated at cardiac outpatient clinics across the Italian national territory. We included patients with known coronary heart disease (CHD) who underwent follow-up visits at various outpatient cardiology clinics. A total of 2532 patients were included (mean age: 67±17 years, 80% male). Among patients with available laboratory data (n=1712), 995 (58%) had LDL-C<70 mg/dL, 717 (42%) had LDL-C≥70 mg/dL, and 470 (27%) had LDL-C<55 mg/dL. Patients who more frequently achieved the recommended LDL-C levels were male, had diabetes, had a higher educational level, and performed intense physical activity. Statins were used in 2339 (92%) patients, high-intensity statins (e.g., rosuvastatin 20/40 mg or atorvastatin 40/80 mg) in 1547 patients (61% of the whole population and 66% of patients on statins), and ezetimibe in 891 patients (35%). Patients receiving high-intensity statins tended to be younger, not to have diabetes, and to have been included in a cardiac rehabilitation program. In a real-world sample of Italian patients with CHD, adherence to lipid-lowering therapy fell markedly short of optimal levels. Many patients did not achieve the LDL-C target of 70 mg/dL, and even fewer reached the LDL-C target of 55 mg/dL. Notably, patients with a lower educational level had a greater likelihood of being undertreated. Strategies aimed at improving preventive interventions for CHD and overcoming social disparities should be evaluated and optimized.

Predictive etiological classification of acute ischemic stroke through interpretable machine learning algorithms: a multicenter, prospective cohort study

BackgroundThe prognosis, recurrence rates, and secondary prevention strategies varied significantly among different subtypes of acute ischemic stroke (AIS). Machine learning (ML) techniques can uncover intricate, non-linear relationships within medical data, enabling the identification of factors associated with etiological classification. However, there is currently a lack of research utilizing ML algorithms for predicting AIS etiology.ObjectiveWe aimed to use interpretable ML algorithms to develop AIS etiology prediction models, identify critical factors in etiology classification, and enhance existing clinical categorization.MethodsThis study involved patients with the Third China National Stroke Registry (CNSR-III). Nine models, which included Natural Gradient Boosting (NGBoost), Categorical Boosting (CatBoost), Extreme Gradient Boosting (XGBoost), Random Forest (RF), Light Gradient Boosting Machine (LGBM), Gradient Boosting Decision Tree (GBDT), Adaptive Boosting (AdaBoost), Support Vector Machine (SVM), and logistic regression (LR), were employed to predict large artery atherosclerosis (LAA), small vessel occlusion (SVO), and cardioembolism (CE) using an 80:20 randomly split training and test set. We designed an SFS-XGB with 10-fold cross-validation for feature selection. The primary evaluation metrics for the models included the area under the receiver operating characteristic curve (AUC) for discrimination and the Brier score (or calibration plots) for calibration.ResultsA total of 5,213 patients were included, comprising 2,471 (47.4%) with LAA, 2,153 (41.3%) with SVO, and 589 (11.3%) with CE. In both LAA and SVO models, the AUC values of the ML models were significantly higher than that of the LR model (P < 0.001). The optimal model for predicting SVO (AUC [RF model] = 0.932) outperformed the optimal LAA model (AUC [NGB model] = 0.917) and the optimal CE model (AUC [LGBM model] = 0.846). Each model displayed relatively satisfactory calibration. Further analysis showed that the optimal CE model could identify potential CE patients in the undetermined etiology (SUE) group, accounting for 1,900 out of 4,156 (45.7%).ConclusionsThe ML algorithm effectively classified patients with LAA, SVO, and CE, demonstrating superior classification performance compared to the LR model. The optimal ML model can identify potential CE patients among SUE patients. These newly identified predictive factors may complement the existing etiological classification system, enabling clinicians to promptly categorize stroke patients’ etiology and initiate optimal strategies for secondary prevention.

The Effect Of Weight Loss With Lifestyle Changes On LDL Cholesterol: Retrospective Cohort Study

Aim: This study aimed to investigate the rate of decrease in lipid levels with effective lifestyle changes (LC) and the minimum body weight loss necessary for effective lipid reduction in obese patients. Method: The study is a retrospective cohort study. The study included 71 patients who were followed up in the obesity clinic, who were diagnosed with hyperlipidemia but did not use any hyperlipidemia treatment. The patients' high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol, triglyceride, body fat ratio and mass, body mass index (BMI), height and weight information were recorded at the first visit and the 6th month. In our study, patients were divided into two groups (based on the weight loss rates in the 6-month follow-up) those who lost less than 10% of their previous weight and those who lost 10% or more weight and their lipid parameters were compared. Results: LDL-C reduction rates of patients classified according to their weight loss rates were found to be statistically significantly (p=0.011) higher in those with 10% or more weight loss than (group 1=18.48%) in those with less than 10% weight loss (group 2=13.04%). Total cholesterol reduction rates were also significantly (p=0.015) higher in the 1st group than in the 2nd group. According to the findings of our study, at least 10% weight loss is required to decrease total cholesterol and LDL-C significantly. Conclusion: Implementation of primary and secondary prevention strategies to reduce the risk of cardiovascular disease is important in the context of primary care. To reach the targeted LDL-C values, the weight monitoring of obese patients should be considered, and the importance of losing at least 10% of weight as one of the first steps should be emphasized.

Efficacy of albumin use in decompensated cirrhosis and real‐world adoption in Australia

AbstractThe current treatment approach to patients with liver cirrhosis relies on the individual management of complications. Consequently, there is an unmet need for an overall therapeutic strategy for primary and secondary prevention of complications. The clinical potential of long‐term albumin infusions supported by recent clinical trials has expanded its indications and holds promise to transform the management and secondary prevention of cirrhosis‐related complications. This renewed interest in albumin comes with inherent controversies, compounding challenges and pressing need for rigorous evaluation of its clinical potential to capitalize on its therapeutic breakthroughs. Australia is among a few countries worldwide to adopt outpatient human albumin infusion. Here, we summarize currently available evidence of the potential benefits of human albumin for the management of multiple liver cirrhosis‐related complications and discuss key challenges for wide application of long‐term albumin administration strategy in Australian clinical practice. Australian Gastroenterological week (AGW), organised by the Gastroenterological Society of Australia (GESA), was held between 9‐11 September 2022. A panel of hepatologists, advanced liver nurses and one haematologist, were invited to a roundtable meeting to discuss the use of long‐term albumin infusions for liver cirrhosis. management in Australia. In this review, we summarise the proceedings of this meeting in context of the current literature.

Low-dose colchicine for the prevention of cardiovascular events after percutaneous coronary intervention: rationale and design of the COL BE PCI trial: Short title: Rationale and design of the COL BE PCI trial

Patients with coronary artery disease (CAD) remain vulnerable to future major atherosclerotic events after revascularization, despite effective secondary prevention strategies. Inflammation plays a central role in the pathogenesis of CAD and recurrent events. To date, there is no specific anti-inflammatory medicine available with proven effective, cost-efficient, and favorable benefit-risk profile, except for colchicine. Initial studies with colchicine have sparked major interest in targeting atherosclerotic events with anti-inflammatory agents, but further studies are warranted to enforce the role of colchicine role as a major treatment pillar in CAD. Given colchicine's low cost and established acceptable long-term safety profile, confirming its efficacy through a pragmatic trial holds the potential to significantly impact the global burden of cardiovascular disease.The COL BE PCI trial is an investigator-initiated, multicenter, double-blind, event-driven trial. It will enroll 2,770 patients with chronic or acute CAD treated with percutaneous coronary intervention (PCI) at 19 sites in Belgium, applying lenient in- and exclusion criteria and including at least 30% female participants. Patients will be randomized between 2 hours and 5 days post-PCI to receive either colchicine 0.5 mg daily or placebo on top of contemporary optimal medical therapy and without run-in period. All patients will have baseline hsCRP measurements and a Second Manifestations of Arterial Disease (SMART) risk score calculation. The primary endpoint is the time from randomization to the first occurrence of a composite endpoint consisting of all-cause death, spontaneous non-fatal myocardial infarction, non-fatal stroke, or coronary revascularization. The trial is event-driven and will continue until 566 events have been reached, providing 80% power to detect a 21 % reduction in the primary endpoint taking a premature discontinuation of 15% into account. We expect a trial duration of approximately 44 months.The COL BE PCI Trial aims to assess the effectiveness and safety of administering low-dose colchicine for the secondary prevention in patients with both chronic and acute coronary artery disease undergoing PCI. Trial registration: ClinicalTrials.gov: NCT06095765.

Bariatric surgery association with risk of recurrent stroke hospitalization among older stroke survivors with obesity: A national inpatient sample study (2016–2019)

Background and aimsThe paucity of large-scale data exploring the effect of prior bariatric surgery on recurrent stroke outcomes in older individuals with obesity who survived a stroke led us to address the gap, with an emphasis on the risk of recurrent stroke and its trends. MethodsRetrospective analysis of the National Inpatient Sample data from 2016 to 2019. Older individuals with obesity who survived a stroke (>65 years) and had a recurrent acute ischemic stroke (AIS) hospitalization, with or without prior bariatric surgery (PBS), were identified using ICD-10 codes. Recurrent stroke trends, demographic characteristics, and comorbidities between the cohorts were compared. ResultsAnalyzing 643,505 older individuals with obesity who survived a stroke, we identified that 11,820 had undergone PBS. Both groups (no PBS vs. PBS) were predominantly female (59.7 % vs. 73.7 %), identified as white (76.5 % vs. 83.8 %), and covered by Medicare (91.7 % vs. 90.7 %). Diabetes, hyperlipidemia, prior myocardial infarction, and peripheral vascular diseases were more common in those without PBS. In contrast, tobacco use disorder, drug abuse, and valvular diseases were more common in those with PBS. There was no significant difference in the prevalence of hypertension between groups.Between 2016 and 2019, recurrent AIS hospitalizations were less frequent in the PBS group (4 %–2.9 %, p = 0.035) while remaining stable in the other group (4.4 %–4.2 %, p = 0.064). The risk of recurrent AIS hospitalization was less frequent in the PBS cohort (aOR: 0.77, 95 % CI: 0.60–0.98). ConclusionPBS in older individuals with obesity who survived a stroke was associated with a 23 % lower risk of recurrent AIS hospitalization with a decreasing trend of prevalence since 2016. These findings could influence clinical practice and contribute to developing secondary prevention strategies for recurrent stroke among these patients.

The role of vitamin D as a preventive strategy in COVID-19 infections: evidence from South Asia

BackgroundRegional evidence on the role of vitamin D in the prevention of COVID-19 and its sequalae remains inconclusive and sparse.ObjectiveThis study aimed to determine the association of COVID-19 status and severity with vitamin D among adults in Colombo District, Sri Lanka.MethodsA sex-matched case–control study was conducted among 104 RT-PCR-confirmed COVID-19 patients recruited from two major hospitals designated as COVID-19 treating centres and 104 RT-PCR negative adults recruited from the catchment area of the two hospitals. Non-fasting blood samples obtained from cases upon hospital admission and from controls upon release from 14-day quarantine period were analysed for serum 25(OH)D using chemiluminescence assay. Serum level < 50.0 nmol/L was identified as vitamin D deficiency (VDD).ResultsCases were older while the controls had fewer persons with co-morbidities. Cases (median = 30.0; IQR = 21.2 nmol/L) had significantly lower 25(OH)D compared to controls (median = 35.9; IQR = 28.3 nmol/L) (p = 0.02), which persisted after adjustments (p = 0.026), along with Sinhalese ethnicity (p < 0.001). VDD was significantly more prevalent in cases (83.7% vs. 71.2%; crude odds ratio (OR) = 2.1; 95% CI 1.1, 4.1); but was not an independent predictor of COVID-19 status (adjusted OR = 1.9; 95% CI 0.6, 5.7). A lower 25(OH)D level was observed in moderate/severe cases (median = 28.0; IQR = 20.4 nmol/L) vs. mild (median = 39.8; IQR = 19.0 nmol/L), however, neither low serum concentrations nor deficiency showed an independent relationship with severity (p > 0.05). Diabetes was the sole predictor of COVID-19 severity (p = 0.022).ConclusionsVitamin D has potential as a primary preventive strategy in preventing COVID-19 like infections, but not as a secondary preventive strategy to reduce its severity.

Diagnostic accuracy of carotid plaque magnetic resonance imaging compared to histopathology in symptomatic carotid artery stenosis

IntroductionVulnerable plaques have been shown to predict ipsilateral cerebral ischemic events and identifying them leads to appropriate secondary stroke prevention strategies. We evaluated the diagnostic accuracy of MR carotid plaque imaging in identifying plaque vulnerability when compared with histopathological findings in patients with symptomatic carotid stenosis who underwent carotid endarterectomy (CEA). MethodsA prospective cohort of forty-five consecutive patients with moderate to severe symptomatic carotid stenosis who underwent CEA at a tertiary Indian hospital had 3 T MRI plaque imaging with multi-parametric protocol between November 2021 and December 2022. Images were analyzed by a vascular radiologist blinded to histopathological data. High-risk plaque characteristics such as lipid rich necrotic core (LRNC), intraplaque hemorrhage (IPH), thin fibrous cap and ulceration were assessed and correlated with histopathological findings as per American Heart Association (AHA) classification using Cohen’s kappa statistics to obtain diagnostic accuracies. ResultsOf the 45 patients, 38(84 %) were males. The mean age was 65 ± 7.7 years and mean duration to CEA from the most recent event was 57 days (57 ± 46 days). A significant correlation between MR plaque imaging and histopathology was noted for IPH (sensitivity-91 %, specificity-86 %, κ = 0.774, p < 0.001), LRNC (sensitivity-92.1 %, specificity-85.7 %, κ = 0.697, p < 0.001), and plaque ulceration (sensitivity-84.6 %, specificity-78.1 %, κ = 0.563, p < 0.001). MRI had an overall sensitivity and specificity of 92.3 % and 84.2 % respectively (κ = 0.77, p < 0.001) in discriminating high risk plaques. ConclusionMR plaque imaging shows a very good correlation with histopathology and can identify unstable high-risk plaques with high accuracy. This may have implication in selection of patients for carotid revascularization in symptomatic carotid stenosis.

Statin use and development and progression of non-alcohol fatty liver disease based on ultrasonography: a cohort study.

Non-alcohol fatty liver disease (NAFLD) has emerged as a public health issue, while no drugs have been specifically approved for treatment. This study aimed to examine the association between statin use and NAFLD occurrence, progression, and regression. A cohort study was designed based on the Kailuan Study and electronic medical records (EMRs) from the Kailuan General Hospital. Participants aged 18 years with statin indication, including statin and non-statin users, were enrolled in 2010-2017. Propensity score-matched cohorts were also used. In the entire cohort, 21 229 non-NAFLD and 22 419 NAFLD patients (including 12 818 mild NAFLD) were included in the final analysis. After a median follow-up of about four years, the incidence of NAFLD occurrence and progression for statin users were lower than those for non-statin users (occurrence: 84.7 vs. 106.5/1000 person-years; progression: 60.7 vs. 75.5/1000 person-years). Compared with non-statin users, the risk of NAFLD occurrence (hazard ratio [HR]: 0.78, 95% confidence interval [CI]: 0.70-0.87) and regression (HR [95%CI], 0.71[0.60-0.84]) was decreased in statin users. The significantly negative association was only observed in those with cumulative statin duration ≥ 2 years (HR [95%CI] for occurrence 0.56 [0.46-0.69] vs. 0.52 [0.30-0.90] for progression) and those with low or moderate ASCVD-risk (HR [95%CI] for occurrence 0.74 [0.66-0.82] vs. 0.68 [0.57-0.80] for progression). No significant correlation was observed between statin use, statin use duration, and NAFLD regression. The PS-matched cohort had similar results. Taking statin may decrease the risk of NAFLD occurrence and progression in the population with statin indication, suggesting the potential role of statin in both primary and secondary prevention strategies for NAFLD, especially among those with low or moderate ASCVD risk.

Enhancement of Psychosocial Competence and Well-Being of Chinese High School Students under the COVID-19 Pandemic: Tin Ka Ping P.A.T.H.S. Project in Mainland China

AbstractMental health problem is a growing problem in mainland China and the situation has worsened under the COVID-19 pandemic. Besides focusing on tertiary and secondary prevention strategies, there is an urgent need to enhance the well-being of adolescents through primary prevention programs. During the pandemic, a positive youth development program entitled “Tin Ka Ping P.A.T.H.S. Program” was implemented in schools in mainland China. In 2022/23 academic year, students were invited to write a weekly diary on their experience about the program after completion of the program (N = 2,337). Qualitative evaluation showed that 98.2% of the students perceived the program was beneficial to their well-being in different domains. Specifically, students perceived the program enhanced their sense of community, school and academic adjustment, interpersonal relations (family relations and peer relations), and intrapersonal competence (including optimism, resilience, positive coping with stress, spirituality, life meaning and cherishing one’s life). In conjunction with other quantitative and qualitative evaluation findings, the triangulated findings strongly suggest Tin Ka Ping P.A.T.H.S. Program is a promising program that enhances the psychosocial competence and quality of life of adolescents.

Frailty and Cardiovascular Health.

The incidence of frailty and cardiovascular disease (CVD) increases as the population ages. There is a bidirectional relationship between frailty and CVD, and both conditions share several risk factors and underlying biological mechanisms. Frailty has been established as an independent prognostic marker in patients with CVD. Moreover, its presence significantly influences both primary and secondary prevention strategies for adults with CVD while also posing a barrier to the inclusion of these patients in pivotal clinical trials and advanced cardiac interventions. This review discusses the current knowledge base on the relationship between frailty and CVD, how managing CVD risk factors can modify frailty, the influence of frailty on CVD management, and future directions for frailty detection and modification in patients with CVD.

Precision Medicine in Acute Coronary Syndromes.

Nowadays, current guidelines on acute coronary syndrome (ACS) provide recommendations mainly based on the clinical presentation. However, greater attention is being directed to the specific pathophysiology underlying ACS, considering that plaque destabilization and rupture leading to luminal thrombotic obstruction is not the only pathway involved, albeit the most recognized. In this review, we discuss how intracoronary imaging and biomarkers allow the identification of specific ACS endotypes, leading to the recognition of different prognostic implications, tailored management strategies, and new potential therapeutic targets. Furthermore, different strategies can be applied on a personalized basis regarding antithrombotic therapy, non-culprit lesion revascularization, and microvascular obstruction (MVO). With respect to myocardial infarction with non-obstructive coronary arteries (MINOCA), we will present a precision medicine approach, suggested by current guidelines as the mainstay of the diagnostic process and with relevant therapeutic implications. Moreover, we aim at illustrating the clinical implications of targeted strategies for ACS secondary prevention, which may lower residual risk in selected patients.

Twenty-five years of sentinel laboratory-based surveillance of shigellosis in a high-income country endemic for the disease, Israel, 1998 to 2022.

BackgroundShigella is a leading cause of moderate-to-severe diarrhoea worldwide and diarrhoeal deaths in children in low- and-middle-income countries.AimWe investigated trends and characteristics of shigellosis and antimicrobial resistance of Shigella sonnei in Israel.MethodsWe analysed data generated by the Sentinel Laboratory-Based Surveillance Network for Enteric Pathogens that systematically collects data on detection of Shigella at sentinel laboratories, along with the characterisation of the isolates at the Shigella National Reference Laboratory. Trends in the shigellosis incidence were assessed using Joinpoint regression and interrupted time-series analyses.ResultsThe average incidence of culture-confirmed shigellosis in Israel declined from 114 per 100,000 population (95% confidence interval (CI): 112-115) 1998-2004 to 80 per 100,000 population (95% CI: 79-82) 2005-2011. This rate remained stable 2012-2019, being 18-32 times higher than that reported from the United States or European high-income countries. After decreasing to its lowest values during the COVID-19 pandemic years (19/100,000 in 2020 and 5/100,000 in 2021), the incidence of culture-confirmed shigellosis increased to 39 per 100,000 population in 2022. Shigella sonnei is the most common serogroup, responsible for a cyclic occurrence of propagated epidemics, and the proportion of Shigella flexneri has decreased. Simultaneous resistance of S. sonnei to ceftriaxone, ampicillin and sulphamethoxazole-trimethoprim increased from 8.5% (34/402) in 2020 to 92.0% (801/876) in 2022.ConclusionsThese findings reinforce the need for continuous laboratory-based surveillance and inform the primary and secondary prevention strategies for shigellosis in Israel and other endemic high-income countries or communities.

Chilean consensus by expert panel using the Delphi technique for primary and secondary prevention of gastric cancer

IntroductionGastric cancer (GC) is the first cause of cancer-related death in Chile and 6th in Latin America and the Caribbean (LAC). Helicobacter pylori (H. pylori) is the main gastric carcinogen, and its treatment reduces GC incidence and mortality. Esophageal-gastro-duodenoscopy (EGD) allows for the detection of premalignant conditions and early-stage GC. Mass screening programs for H. pylori infection and screening for premalignant conditions and early-stage GC are not currently implemented in LAC. The aim of this study is to establish recommendations for primary and secondary prevention of GC in asymptomatic standard-risk populations in Chile. MethodsTwo on-line synchronous workshops and a seminar were conducted with Chilean experts. A Delphi panel consensus was conducted over 2 rounds to achieve >80% agreement on proposed primary and secondary prevention strategies for the population stratified by age groups. Results10, 12, and 12 experts participated in two workshops and a seminar, respectively. In the Delphi panel, 25 out of 37 experts (77.14%) and 28 out of 52 experts (53.85%) responded. For the population aged 16–34, there was no consensus on non-invasive testing and treatment for H. pylori, and the use of EGD was excluded. For the 35–44 age group, non-invasive testing and treatment for H. pylori is recommended, followed by subsequent test-of-cure using non-invasive tests (stool antigen test or urea breath test). In the ≥45 age group, a combined strategy is recommended, involving H. pylori testing and treatment plus non-invasive biomarkers (H. pylori IgG serology and serum pepsinogens I and II); subsequently, a selected group of subjects will undergo EGD with gastric biopsies (Sydney Protocol), which will be used to stratify surveillance according to the OLGA classification (Operative Link for Gastritis Assessment); every 3 years for OLGA III–IV and every 5 years for OLGA I–II. ConclusionA “test-and-treat” strategy for H. pylori infection based on non-invasive studies (primary prevention) is proposed in the 35–44 age group, and a combined strategy (serology and EGD) is recommended for the ≥45 age group (primary and secondary prevention). These strategies are potentially applicable to other countries in LAC.

Multidisciplinary Approach to Patent Foramen Ovale Closure for Cryptogenic Stroke: Brain-Heart Board Experience.

Patent foramen ovale (PFO) is present in approximately 25% of adult population. The prevalence of PFO is high in patients with cryptogenic stroke suggesting paradoxical embolism. PFO closure in carefully selected patients is an effective secondary preventive strategy in these patients. We report predictors of management recommendations by the multidisciplinary Board and their impact on outcomes. Brain-Heart Board comprises vascular and interventional neurology and cardiology subspecialties (structural, electrophysiology, and cardiac imaging). Adult patients referred to the Board for consideration of PFO closure between October 2017 to March 2021 were included in this retrospective cohort analysis. Demographics, comorbid conditions, risk of paradoxical embolism (RoPE) score, event frequencies (transient ischemic attack [TIA] or stroke, intracranial hemorrhage [ICH], post-PFO closure cardiac arrhythmias), and modified Rankin Scale (mRS) at 1 year were compared between the groups (PFO closure vs medical management). Multivariable logistic regression was used to identify factors associated with management recommendation and chi-square tests to test differences in outcomes for patients according to management. Two hundred seventy patients (229 stroke; 41 TIA) were discussed by the Board for PFO closure. 119 (44.0%) patients were recommended for PFO closure of which 117 (98.3%) had evidence of ischemic infarct on imaging. In univariate analysis, age was similar (50 ± 11.9 vs 52 ± 12.8, p = 0.17), but RoPE score was higher in closure as compared with the medical management group (6 [IQR 5-7] vs 5 [IQR 4-7], p < 0.05). In multivariable analysis, TIA as the index event was an independent predictor of Board recommendation against PFO closure (OR 0.05, 95% CI 0.01-0.19, p < 0.05). Event frequency was low in both cohorts (5.9% vs 4.8%, p > 0.05) and comprised cardiac arrhythmias (6 cases of atrial fibrillation and 1 ICH in closure group; 1 TIA and 1 recurrent stroke in medical management group). Excellent functional outcome (mRS 0-1) was similar in both cohorts (66.3% vs 70.7%, p > 0.05) at 1 year. Multidisciplinary Brain-Heart Board provides a clinical practice model of collaborative care to ensure proper patient selection for PFO closure. TIA as the index event is associated with recommendation of medical management by the multidisciplinary Brain-Heart Board.

Navigating non-medical androgen use: Towards a harm reduction paradigm

Non-medical androgen use is on the rise, with short-term side effects being well-documented whereas long-term consequences remain less understood but are likely to entail cardiovascular illness and permanent endocrine disruptions. Current educational initiatives are falling short in curbing this significant increase, signaling the need for a different approach. In this context, harm reduction emerges as a promising secondary prevention strategy. The key principles of the harm reduction approach outlined in this article emphasize educating individuals about side effects, limiting androgen use, and monitoring health closely. Successful implementation of this strategy hinges upon healthcare providers possessing expertise in the field, fostering non-judgmental interpersonal relationships, and securing cooperation of the athlete. The efficacy of this strategy will be rigorously evaluated in the HARNAS trial, comparing its outcomes with those of a historical control group. The findings from this trial are anticipated to be published in the coming years, shedding light on the effectiveness of this pioneering approach.

Secondary and Tertiary Prevention for Adolescent Dating Violence: A Systematic Review.

Adolescent dating violence (ADV) is a pervasive public health issue associated with numerous social, psychological, and physical health consequences. Thus, programs are often implemented to prevent ADV and promote healthy relationships. Although there is a growing body of literature on primary ADV prevention strategies (i.e., prevention), little is known about secondary (e.g., early intervention) and tertiary (e.g., manage and reduce impact once occurring) ADV prevention approaches. This systematic review, guided by Cochrane Review methodology, summarizes available evidence on secondary and tertiary ADV preventive interventions. The search had no date restriction and was conducted in eight databases in November 2022. Studies published in English and/or Spanish were included if they described the development, implementation, and/or evaluation of a secondary and/or tertiary preventive intervention for ADV. After screening the titles and abstracts of 3,645 articles, 31 articles were included in this study, reporting on 14 secondary, 3 primary/secondary, 6 secondary/tertiary, and 1 tertiary ADV preventive intervention. The included studies highlighted that available secondary ADV prevention strategies are quite effective in preventing ADV victimization and perpetration, and that the effects may be strongest for teens with a higher risk of being involved in an abusive relationship. The only included study that reported on a tertiary intervention was a program development study. Based on the lack of tertiary prevention strategies available for ADV, clinical interventions focusing on treating and reducing negative consequences after ADV are needed.

The influence of the health status and functional capacity assessment of older people with heart failure on the participation in a cardiac rehabilitation program after myocardial infarction

Abstract Background Cardiac rehabilitation (CR) after myocardial infarction (MI), conducted by a multidisciplinary team, is considered to be the most effective secondary prevention strategy. CR might be particularly beneficial in older patients, who often suffer from heart failure (HF) and other comorbidities. Low enrolment in CR programs is observed in various age groups despite the proven effectiveness of CR in the reduction of subsequent ischemic episodes, hospitalization, and mortality risk. Purpose The study aimed to analyze the impact of the health status and functional capacity assessment of elderly patients with HF using the Vulnerable Elders Survey (VES-13) scale on the willingness to participate in the CR program as part of the national Comprehensive Care Program after Myocardial Infarction. Methods The analysis of the medical records of MI patients, who were hospitalized between 2017 and 2023 and met the inclusion criteria for CR was performed. People included in the study were ≥60 years of age and had previously been diagnosed with HF. The study included 350 people who underwent VES-13 assessment during hospitalization. The median age of the studied group was 74 (IQR 68-81), with the majority of males (59.1%). Results The willingness to participate in CR was declared by 26.3% of respondents. The median VES-13 score was 3 (IQR 2-7) points and was higher in patients who did not want to participate in CR [3 (IQR 2-7) vs 2 (IQR 1-3), p &amp;lt;0.0001]. In the group of patients who scored &amp;lt;3 points in the VES-13 scale, there was a significantly higher percentage of patients declaring their willingness to participate in CR compared to the group with ≥3 points (38.8% vs 18.5%, p=0.0001). Univariate analysis showed that all parameters assessed by the VES-13 scale had a significant impact on patients' willingness to participate in CR (Figure 1). Independent factors determining patients' declaration were age, difficulties in reaching or extending arms above the shoulder level, and limitations in shopping for personal items (like toilet items or medicines) (Figure 2). Conclusion The VES-13 scale can help to identify patients with HF after MI who require additional support and motivation in the decision process to participate in coordinated care and early CR. Limitations in the everyday functioning of elderly patients with HF determine the lack of willingness to participate in CR after MI. It is necessary to carry out intensive educational and motivational activities to improve the recruitment to the CR program.

Coronary artery disease management in older adults: revascularization and exercise training.

The mean age of patients with coronary artery disease (CAD) is steadily increasing. In older patients, there is a tendency to underutilize invasive approach, coronary revascularization, up-to-date pharmacological therapies, and secondary prevention strategies, including cardiac rehabilitation. Older adults with CAD commonly exhibit atypical symptoms, multi-vessel disease involvement, complex coronary anatomy, and a higher presence of risk factors and comorbidities. Although both invasive procedures and medical treatments are characterized by a higher risk of complications, avoidance may result in a suboptimal outcome. Often, overlooked factors, such as coronary microvascular disease, malnutrition, and poor physical performance, play a key role in determining prognosis, yet they are not routinely assessed or addressed in older patients. Historically, clinicians have relied on sub-analyses or observational findings to make clinical decisions, as older adults were frequently excluded or under-represented in clinical studies. Recently, dedicated evidence through randomized clinical trials has become available for older CAD patients. Nevertheless, the management of older CAD patients still raises several important questions. This review aims to comprehensively summarize and critically evaluate this emerging evidence, focusing on invasive management and coronary revascularization. Furthermore, it seeks to contextualize these interventions within the framework of improved risk stratification tools for older CAD patients, through user-friendly scales along with emphasizing the importance of promoting physical activity and exercise training to enhance the outcomes of invasive and medical treatments. This comprehensive approach may represent the key to improving prognosis in the complex and growing patient population of older CAD patients.

Peripheral Arterial Disease in Nova Scotia: Increased Prevalence, Low Public Awareness, and Poor Edinburgh Claudication Questionnaire Sensitivity

BackgroundThis study had the following 3 goals: (i) to assess the prevalence of peripheral arterial disease (PAD) in a Nova Scotian population; (ii) to evaluate the validity of the Edinburgh Claudication Questionnaire (ECQ) in a Nova Scotian context; and (iii) to evaluate Nova Scotian public knowledge about PAD. MethodsParticipants were recruited from 8 sites across Nova Scotia. In 2022, they were recruited at Heartland Tour (HLT) sites—a provincial health-promotion campaign. In 2023, they were recruited in communities coinciding with HLT sites (public [PUB]). Participants completed a demographics questionnaire, ECQ, and had an ankle–brachial index (ABI) measurement. An ABI of < 0.9 was considered positive for presence of PAD. ResultsA total of 417 participants were recruited, 263 from HLT, and 154 from PUB. A total of 398 participants had ABI scores resulting in a PAD prevalence of 2.81% (249 participants) in the HLT group, and 5.37% (149 participants) in the PUB group. A total of 394 participants had both ABI and ECQ scores, with a found sensitivity of 6.67% (confidence interval 0.17%-31.95%) and specificity of 97.63% (confidence interval 95.54%-98.91%). A total of 75% of participants (311 of 417) did not have prior knowledge of PAD. ConclusionsThe PAD prevalences in both cohorts were higher than anticipated, with the PUB cohort being more than double the national average. This finding raises the following question: should specific PAD primary and/or secondary prevention strategies be targeted within the province? Our study demonstrated that a public-awareness campaign would be highly impactful, owing to a low level of awareness of PAD within both cohorts, and that the ECQ was not an effective screening tool when used on the Nova Scotian population.