Cardiovascular Medication Use Research Articles

Longitudinal association of premature atrial contractions with atrial fibrillation and brain ischemia in people with type 2 diabetes: The Hoorn Diabetes Care System cohort

BackgroundPremature atrial contractions (PACs) are potential markers for imminent onset of both atrial fibrillation (AF) and brain ischemia (BI; transient ischemic attack [TIA] or ischemic stroke). We investigated the association of PACs with incident AF and BI events separately, and of incident AF with BI events in people with type 2 diabetes (T2D) without pre-existing AF or cerebrovascular disease. MethodsA prospective longitudinal study of 12,242 people with T2D without known AF or cerebrovascular disease from the Hoorn Diabetes Care System cohort. Annual measurements (1998–2018) included cardiovascular risk factors, over 85,000 ECGs, and self-reported cardiovascular events. We assessed the association of PACs with incident AF and BI events and of incident AF with BI events using time-dependent Cox-regression models, adjusted for time-varying cardiovascular risk factors and medication use (Hazard Ratios with 95%CIs). ResultsThe baseline mean age was 62.2 ± 11.9 years. During a median follow-up of 7.0 (IQR 3.4–11.0) years, 1031 (8.4 %) participants had PACs, and 566 (4.6 %) had incident AF at any of the median 6 (IQR 3–10) annual ECG recordings. BI events occurred in 517 (4.2 %) people (304 TIAs, 213 ischemic strokes). After adjustment, PACs were associated with incident AF (Hazard Ratio, 1.96 (95%CI, 1.53–2.50)), but not with overall BI events (1.09 (0.76–1.56)), or with TIA (0.91 (0.57–1.46)) or ischemic stroke (1.50 (0.88–2.54)) separately. AF was not associated with BI events (0.95 (0.55–1.63)). ConclusionsIn people with T2D without a history of AF or BI events, PACs are associated with a two-fold increased risk of incident AF.

Differences in Medication Use by Gender and Race in Hospitalized Persons Living with Dementia.

The purpose of this study was to describe differences in treatment of White versus Black older adults, males versus females, and those living at home, assisted living, or nursing home communities with regard to the use of psychotropic, pain, and cardiovascular medications. Baseline data from the first 352 participants in the study, implementation of Function-Focused Care for Acute Care Using the Evidence Integration Triangle, were used. Data included age, gender, race, comorbidities, admission diagnosis, and living location prior to hospitalization, the Saint Louis University Mental Status exam, the modified Charlson Comorbidity Index, the Pain Assessment in Advanced Dementia scale, the Confusion Assessment Method, and medications prescribed. Generalized linear mixed model analyses were done, controlling for race or gender (depending on which comparison analysis was being done), age, cognitive status, hospital, delirium, and comorbidities. Medication use was significantly higher for White older adults, compared to Black older adults, for antidepressants, anxiolytics, non-opioid pain medications, and opioids and lower for antihypertensives. Females received more anxiolytics than their male counterparts. There were differences in medication use by living location with regard to non-opioid pain medication, antipsychotics, statins, and anticoagulants. The findings provide some current information about differences in medication use across groups of individuals and can help guide future research and hypothesis testing for approaches to minimizing these differences in treatment.

A comparison of two pre-race medical screening tools in 5771 running race entrants-SAFER XXVIII.

To determine if two pre-race screening tools (abbreviated tool of two open-ended pre-race medical screening questions [ABBR] vs. a full pre-race medical screening tool [FULL]) identify running race entrants at higher risk for medical encounters (MEs) on race day. 5771 consenting race entrants completed both an ABBR and a FULL pre-race screening questionnaire for the 2018 Comrades Marathon (90 km). ABBR tool questions were (1) allergies, and (2) known medical conditions and/or prescription medication use. The FULL tool included multiple domains of questions for chronic diseases including cardiovascular disease (CVD), symptoms, risk factors, allergies and medication use. ABBR responses were manually coded and compared to the FULL tool. The prevalence (%: 95%CI), and the test for equality of prevalence of entrants identified by the ABBR vs. FULL tool is reported. The ABBR identified fewer entrants with allergies (ABBR = 7.9%; FULL = 10.4%: p = 0.0001) and medical conditions/medication use (ABBR = 8.9%; FULL = 27.4%: p = 0.0001). The ABBR tool significantly under-reported entrants with history of cardiovascular disease (CVD), CVD risk factors, other chronic diseases and prescription medication vs. the FULL tool (p = 0.0001). The ABBR tool identified fewer entrants in the "high" (ABBR = 3.4%; FULL = 12.4%) and "very high" risk (ABBR = 0.5%; FULL = 3.4%) categories for race day MEs (p = 0.0001). An abbreviated pre-race screening tool significantly under-estimates chronic medical conditions, allergies, and race entrants at higher risk for MEs on race day, compared with a full comprehensive screening tool. We recommend that a full pre-race medical screening tool be used to identify race entrants at risk for MEs.

The Study of Risk Factors and The Predict Model of Cerebral Microbleeds.

To determine the association of cardiovascular risk factors with the presence and anatomic location of CMBs and construct a factor-based evaluating model to predict a high CMBs burden. We assessed the relation of age, male, various cardiovascular risk factors, medication use, stroke histories and white matter hyperintensities (WMH) to the presence and location of CMBs with univariate analysis and multiple logistic regression. Finally, we added risk factors for a high CMBs burden to a factor-based evaluating model score. 485 patients were included in our study. CMBs were more prevalent with advanced age, male sex, more cardiovascular risk factors and WMH. Alcohol use, hemorrhagic stroke history and the degree of deep white matter hyperintensity(DWMH) were independent predictors for a high CMBs burden(≥10). We finally structured a prediction model-HPSAD3 that consisted of hypertension, alcohol use, hemorrhagic stroke history and WMH to predict a high CMBs burden. The model-HPSAD3 has a higher positive predict value (77.08%) and negative predict value(75.89%) to predict a high CMBs burden when the cut-off score is 4. Hypertension, alcohol use, hemorrhagic stroke history and WMH were added into the model- HPSAD3, and there was a higher possibility of patients with CMBs ≥10 when the score of HPSAD3 ≥4.

Effects of sodium-glucose co-transporter-2 inhibitors by background cardiovascular medications: A systematic review and meta-analysis.

To explore whether the beneficial cardiovascular (CV) effect of sodium-glucose co-transporter-2 (SGLT-2) inhibitors is consistent with or without concurrent use of CV medications in patients with type 2 diabetes, heart failure (HF) or chronic kidney disease. We searched Medline and Embase up to September 2022 for CV outcomes trials. The primary endpoint was the composite of cardiovascular (CV) death or hospitalization for HF. Secondary outcomes included the individual components of CV death, hospitalization for HF, death from any cause, major adverse CV events or renal events, volume depletion and hyperkalaemia. We pooled hazard ratios (HRs) and risk ratios alongside 95% confidence intervals (CIs). We included 12 trials comprising 83 804 patients. SGLT-2 inhibitors reduced the risk of CV death or hospitalization for HF regardless of background use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), angiotensin receptor-neprilysin inhibitors (ARNIs), b-blockers, diuretics, mineralocorticoid receptor antagonists (MRAs), or triple combination therapy of either an ACEI/ARB plus b-blocker plus MRA, or an ARNI plus b-blocker plus MRA (HRs ranged from 0.61 to 0.83; P > .1 for each subgroup interaction). Similarly, no subgroup differences were evident for most analyses for the secondary outcomes of CV death, hospitalization for HF, all-cause mortality, major adverse CV or renal events, hyperkalaemia and volume depletion rate. The benefit of SGLT-2 inhibitors seems to be additive to background use of CV medications in a broad population of patients. These findings should be interpreted as hypothesis generating because most of the subgroups analysed were not prespecified.

Association of left ventricular ejection fraction and long axis function across health and disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Global longitudinal shortening (GLSh) 1,2 and left ventricular ejection fraction (LVEF) are different measures of left ventricular function. LVEF is well-established, but can miss early or mild disease. GLSh, which quantifies long-axis shortening, is easy to measure, and has been shown to have superior reproducibility and prognostication ability than global longitudinal strain3,4. Purpose To assess the relationship between GLSh and EF measured using CMR in a large cohort representing health (healthy volunteers, athletes) and disease (hypertension, aortic stenosis, hypertrophic cardiomyopathy(HCM),cardiac amyloidosis, Fabry disease). Methods CMR scans from a study cohort of 932 subjects were analysed (121 healthy volunteers, 278 athletes, 40 patients with hypertension, 76 severe aortic stenosis, 164 HCM, 51 cardiac amyloidosis, 202 Fabry). EF and GLSh were automatically measured from standard CMR SSFP cine images using machine learning methods described previously3,5. Correlation coefficients between GLSh and LVEF were calculated for each disease category. Normal reference ranges for LVEF and GLSh were estimated from a subset of n=4,342 healthy subjects from the UK Biobank, who had no history of cardiovascular disease or medication use. Results The lower limit of normal in the UK Biobank healthy subjects was 55% for EF and 13% for GLSh. Across the study cohort, for subjects with normal LVEF, only a small minority of healthy volunteers (n=1, 0.8%) and athletes(n=2; 0.7%) had low GLSh, whereas rates increased progressively in hypertension(n=3;9%), Fabry(n=61;31%), aortic stenosis(n=26;44%), HCM (n=87; 56%), and cardiac amyloidosis(N=28; 93%). Conversely, few subjects (n=8/932;0.1%) have the opposite: normal LGSh but low LVEF(Figure 1). The relationship between LVEF and GLSh is shown in Figure 2. Apart from HCM (r=0.019,p = 0.8), all other diseases show a significant association between GLSh and LVEF, with progressively higher correlation from healthy volunteers (r=0.33 p<0.001) to cardiac amyloidosis (r=0.33; p = 0.0016), athletes (r=0.44; p<0.001), and hypertension (R=0.6; p<0.001), with aortic stenosis showing highest correlation (r=0.68,p<0.001). Fabrys patients showed the reverse trend, with an inverse correlation between GLSh and LVEF (r=-0.34; p<0.001). Conclusions In health, impaired GLSh is rare when LVEF is normal, however across diseases with hypertrophy, GLSh impairment is common, illustrating the potential of GLSh to detecting early or mild systolic impairment. There are unexpectedly different associations between GLS and EF. In some diseases, these appears to measure the same aspects (health/AS/hypertension), but in others they are not well correlated with GLS providing new information. In Fabry, there is an unexpected inverse relationship. Further work is needed to understand this.

Diabetes treatment for persons with severe mental illness: A registry-based cohort study to explore medication treatment differences for persons with type 2 diabetes with and without severe mental illness.

It has been argued that persons with severe mental illness (SMI) receive poorer treatment for somatic comorbidities. This study assesses the treatment rates of glucose-lowering and cardiovascular medications among persons with incident type 2 diabetes (T2D) and SMI compared to persons with T2D without SMI. We identified persons ≥30 years old with incident diabetes (HbA1c ≥ 48 mmol/mol and/or glucose ≥ 11.0 mmol/L) from 2001 through 2015 in the Copenhagen Primary Care Laboratory (CopLab) Database. The SMI group included persons with psychotic, affective, or personality disorders within five years preceding the T2D diagnosis. Using a Poisson regression model, we calculated the adjusted rate ratios (aRR) for the redemption of various glucose-lowering and cardiovascular medications up to ten years after T2D diagnosis. We identified 1,316 persons with T2D and SMI and 41,538 persons with T2D but no SMI. Despite similar glycemic control at diagnosis, persons with SMI redeemed a glucose-lowering medication more often than persons without SMI in the period 0.5-2 years after the T2D diagnosis; for example, the aRR was 1.05 (95% CI 1.00-1.11) in the period 1.5-2 years after the T2D diagnosis. This difference was mainly driven by metformin. In contrast, persons with SMI were less often treated with cardiovascular medications during the first 3 years after T2D diagnosis, e.g., in the period 1.5-2 years after T2D diagnosis, the aRR was 0.96 (95% CI 0.92-0.99). For people with SMI in addition to T2D, metformin is more likely to be used in the initial years after T2D diagnosis, while our results suggest potential room for improvement regarding the use of cardiovascular medications.

Temporal Changes in Obesity-Related Medication After Bariatric Surgery vs No Surgery for Obesity

Bariatric surgery can resolve hyperlipidemia, cardiovascular disease, and diabetes, but the long-term postoperative trajectories of medications for these conditions are unknown. To clarify the long-term use of lipid-lowering, cardiovascular, and antidiabetic medication after bariatric surgery compared with no surgery for morbid obesity. This population-based cohort study took place in Sweden (2005-2020) and Finland (1995-2018) and included individuals diagnosed with obesity. Analysis took place between July 2021 and January 2022. Bariatric surgery (gastric bypass or sleeve gastrectomy) patients using lipid-lowering, cardiovascular, or antidiabetic medication were compared with 5 times as many control patients with an obesity diagnosis treated with no surgery, matched for country, age, sex, calendar year, and medication use. Proportions with 95% CIs of lipid-lowering, cardiovascular, or antidiabetic medication. A total of 26 396 patients underwent bariatric surgery (with gastric bypass or sleeve gastrectomy) (17 521 [66.4%] women; median [IQR] age, 50 [43-56] years) and 131 980 matched control patients (87 605 [66.4%%] women; median [IQR] age, 50 [43-56] years) were included. The proportion of lipid-lowering medication after bariatric surgery decreased from 20.3% (95% CI, 20.2%-20.5%) at baseline to 12.9% (95% CI, 12.7%-13.0%) after 2 years and 17.6% (95% CI, 13.3%-21.8%) after 15 years, while it increased in the no surgery group from 21.0% (95% CI, 20.9%-21.1%) at baseline to 44.6% (95% CI, 41.7%-47.5%) after 15 years. Cardiovascular medications were used by 60.2% (95% CI, 60.0%-60.5%) of bariatric surgery patients at baseline, decreased to 43.2% (95% CI, 42.9%-43.4%) after 2 years, and increased to 74.6% (95% CI, 65.8%-83.4%) after 15 years, while it increased in the no surgery group from 54.4% (95% CI, 54.3%-54.5%) at baseline to 83.3% (95% CI, 79.3%-87.3%) after 15 years. Antidiabetic medications were used by 27.7% (95% CI, 27.6%-27.9%) in the bariatric surgery group at baseline, decreased to 10.0% (95% CI, 9.9%-10.2%) after 2 years, and increased to 23.5% (95% CI, 18.5%-28.5%) after 15 years, while it increased in the no surgery group from 27.7% (95% CI, 27.6%-27.7%) at baseline to 54.2% (95% CI, 51.0%-57.5%) after 15 years. In this study, undergoing bariatric surgery was associated with a substantial and long-lasting reduction in the use of lipid-lowering and antidiabetic medications compared with no surgery for obesity, while for cardiovascular medications this reduction was only transient.

Rapid recovery of post-stroke cardiac autonomic dysfunction - causes to be considered.

Acute stroke frequently causes cardiovascular-autonomic dysfunction (CAD). Studies of CAD-recovery are inconclusive while post-stroke arrhythmias may wane within 72 hours. We evaluated whether post-stroke CAD recovers within 72 hours upon stroke-onset in association with neurological improvement or increased use of cardiovascular medication. In 50 ischemic-stroke patients (68±13 years) who - prior to hospital-admission - had no known diseases nor took medication affecting autonomic modulation, we assessed NIHSS-scores, RR-intervals (RRI), systolic, diastolic blood-pressures (BP), respiration-rate, parameters reflecting total autonomic modulation [RRI-standard-deviation, RRI-total-powers], sympathetic [RRI-low-frequency-powers, BPsys-low-frequency-powers] and parasympathetic modulation [RMSSD, RRI-high-frequency-powers], and baroreflex-sensitivity within 24 hours (assessment-1) and 72 hours after stroke-onset (assessment-2) and compared data to those of 31 healthy-controls (64±10 years). We correlated delta-NIHSS-values (assessment-1 - assessment-2) with delta-values of autonomic parameters (Spearman-Rank-correlation tests; significance: P<0.05). At assessment-1, patients were not yet on vasoactive medication and had higher systolic blood pressure, respiration-rate, heart rate, i.e. lower RRIs, but lower RRI-Standard-Deviation, RRI-coefficient-of-variance, RRI-low-frequency-powers, RRI-high-frequency-powers, RRI-total-powers, RMSSDs, and baroreflex-sensitivity. At assessment-2, patients were on antihypertensives, had higher RRI-Standard-Deviation, RRI-coefficient-of-variance, RRI-low-frequency-powers, RRI-high-frequency-powers, RRI-total-powers, RMSSDs, and baroreflex-sensitivity but lower systolic blood pressure and NIHSS-values than at assessment-1; values no longer differed between patients and controls except for lower RRIs and higher respiration-rate in patients. Delta-NIHSS-scores correlated inversely with delta-values of RRI-Standard-Deviation, RRI-coefficient-of-variance, RMSSDs, RRI-low-frequency-powers, RRI-high-frequency-powers, RRI-total-powers, and baroreflex-sensitivity. In our patients, CAD-recovery was almost complete within 72 hours after stroke-onset and correlated with neurological improvement. Most likely, early initiation of cardiovascular medication and probably attenuating stress supported rapid CAD-recovery.

The underutilization of preventive cardiovascular measures in patients with cancer: an analysis of the Behavioural Risk Factor Surveillance System, 2011-22.

This study aimed to characterize the influence of a cancer diagnosis on the use of preventive cardiovascular measures in patients with and without cardiovascular disease (CVD). Data from the Behavioural Risk Factor Surveillance System Survey (spanning 2011-22) were used. Multivariable logistic regression models adjusted for potential confounders were applied to calculate average marginal effects (AME), the average difference in the probability of using a given therapy between patients with and without cancer. Outcomes of interest included the use of pharmacological therapies, physical activity, smoking cessation, and post-CVD rehabilitation. Among 5 012 721 respondents, 579 114 reported a history of CVD (coronary disease or stroke), and 842 221 reported a diagnosis of cancer. The association between cancer and the use of pharmacological therapies varied between those with vs. without CVD (P-value for interaction: <0.001). Among patients with CVD, a cancer diagnosis was associated with a lower use of blood pressure-lowering medications {AME: -1.46% [95% confidence interval (CI): -2.19% to -0.73%]}, lipid-lowering medications [AME: -2.34% (95% CI: -4.03% to -0.66%)], and aspirin [AME: -6.05% (95% CI: -8.88% to -3.23%)]. Among patients without CVD, there were no statistically significant differences between patients with and without cancer regarding pharmacological therapies. Additionally, cancer was associated with a significantly lower likelihood of engaging in physical activity in the overall cohort and in using post-CVD rehabilitation regimens, particularly post-stroke rehabilitation. Preventive pharmacological agents are underutilized in those with cancer and concomitant CVD, and physical activity is underutilized in patients with cancer in those with or without CVD. •This paper compared the use of preventive cardiovascular measures, both pharmaceutical and non-pharmaceutical, in patients with and without cancer.•In patients with cardiovascular disease and cancer, there is a lower use of preventive cardiovascular medications compared with those with cardiovascular disease but without cancer. This includes a lower utilization of blood pressure-lowering medications, cholesterol-lowering medications, and aspirin.•Patients with cancer reported lower levels of exercise but higher levels of smoking cessation compared with those without cancer.

Effects of Dapagliflozin in Chronic Kidney Disease, With and Without Other Cardiovascular Medications: DAPA-CKD Trial.

Background The DAPA-CKD (Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease) trial (NCT03036150) demonstrated that dapagliflozin reduced the risk of kidney and cardiovascular events in patients with chronic kidney disease and albuminuria with and without type 2 diabetes. We aimed to determine whether baseline cardiovascular medication use modified the dapagliflozin treatment effect. Methods and Results We randomized 4304 adults with baseline estimated glomerular filtration rate 25 to 75 mL/min per 1.73 m2 and urinary albumin:creatinine ratio 200 to 5000 mg/g to dapagliflozin 10 mg or placebo once daily. The primary end point was a composite of ≥50% estimated glomerular filtration rate decline, end-stage kidney disease, and kidney or cardiovascular death. Secondary end points included a kidney composite end point (primary composite end point without cardiovascular death), a cardiovascular composite end point (hospitalized heart failure or cardiovascular death), and all-cause mortality. We categorized patients according to baseline cardiovascular medication use/nonuse. Patients were required by protocol to receive a stable (and maximally tolerated) dose of a renin-angiotensin-aldosterone system inhibitor. We observed consistent benefits of dapagliflozin relative to placebo, irrespective of baseline use/nonuse of renin-angiotensin-aldosterone system inhibitors (98.1%), calcium channel blockers (50.7%), β-adrenergic antagonists (39.0%), diuretics (43.7%), and antithrombotic (47.4%), and lipid-lowering (15.0%) agents. Use of these drugs in combination with dapagliflozin did not increase the number of serious adverse events. Conclusions The safety profile and efficacy of dapagliflozin on kidney and cardiovascular end points in patients with chronic kidney disease were consistent among patients treated and not treated at baseline with a range of cardiovascular medications. Registration Information clinicaltrials.gov. Identifier: NCT03036150.

Nursing Assessment of Cardiovascular System: Importance of History Taking and Physical Examination

Assessment of a patient's cardiovascular system is crucial in identifying potential problems, determining a diagnosis, and creating a care plan. The nursing assessment process involves both history taking and physical examination. History taking is important in obtaining information about the patient's past medical history, risk factors for cardiovascular disease, symptoms, and medication use. This information can help to identify potential problems, such as high blood pressure or heart disease, and provide a baseline for comparison during subsequent assessments. Physical examination includes evaluating the patient's vital signs, such as blood pressure, heart rate, and rhythm, and listening to the heart and lungs for sounds that may indicate problems, such as murmurs or crackles. The examination may also involve palpating for peripheral pulses, evaluating for edema, and assessing skin color and temperature. Together, the information gathered during history taking and physical examination forms a comprehensive picture of the patient's cardiovascular system and provides the foundation for an effective nursing care plan.

Distinctive Signs of Disease as Deterrents for the Endothelial Function: A Systematic Review.

Endothelial integrity plays a major role in homeostasis and is responsive to the numerous endogenous factors released. While its functional role in vascular tone is well described, its role in the pathophysiology of cardiovascular disease is of interest as a potential therapeutic target. We performed a systematic review to provide an overview of new therapeutic and diagnostic targets for the treatment of coronary artery disease related to endothelial dysfunction. Databases of PubMed, Ovid's version of MEDLINE, and EMBASE were interrogated with appropriate search terms. Inclusion criteria have been met by 28 studies that were included in the final systematic review. We identified inflammation, pulmonary hypertension, diabetes mellitus and Fabry disease as pathophysiological mechanisms and explored the therapeutic options related to these conditions including medications such as Canakinumab. Endothelial dysfunction has a key role in several different pathophysiological processes which can be targeted for therapeutic options. Ongoing research should be targeted at making the transition to clinical practice. Further research is also needed on understanding the amelioration of endothelial dysfunction with the use of cardiovascular medications.

Real-World Racial Variation in Treatment and Outcomes Among Patients with Peripheral Artery Disease.

Prior studies have found considerable disparities in prevalence and outcomes for patients with peripheral arterial disease (PAD). This study compared rates of diagnostic testing, treatment patterns, and outcomes after diagnosis of PAD among commercially insured Black and White patients in the United States. Optum's de-identified Clinformatics® Data Mart Database (1/2016-6/2021) were used to identify Black and White patients with PAD; first PAD diagnosis was deemed study index date. Baseline demographics, markers of disease severity, and healthcare costs were compared between cohorts. Patterns of medical management and rates of major adverse limb events (MALE; including acute or chronic limb ischemia, lower-limb amputation) and cardiovascular (CV) events (stroke, myocardial infarction) during the available follow-up period were described. Outcomes were compared between cohorts using multinomial logistic regression models, Kaplan-Meier survival analysis, and Cox proportional hazards models. A total of 669,939 patients were identified, with 454,382 White patients and 96,162 Black patients. Black patients were younger on average (71.8years vs. 74.2years), but had higher comorbid burden, concomitant risk factors, and CV medication use at baseline. Prevalence of diagnostic testing, revascularization procedures, and medication use was numerically higher among Black patients. Black patients were also more likely than the White patients to receive medical therapy without a revascularization procedure [adjusted odds ratio with 95% confidence interval (CI)=1.47 (1.44-1.49)]. However, Black patients with PAD had higher incidence of MALE and CV events than White patients [adjusted hazard ratio for composite event (95% CI)=1.13, (1.11-1.15)]. Except myocardial infarction, the hazards of individual components of MALE and CV events were also significantly higher among Black patients with PAD. Results of this real-world study suggest that Black patients with PAD have higher disease severity at the time of diagnosis and are at increased risk of experiencing adverse outcomes following diagnosis.

Cardiac symptoms and yield of diagnostic tests among primary care patients with and without diabetes

AimsTo compare the symptoms, diagnostic tests used, and clinical diagnoses made among diabetic and non-diabetic patients. MethodsThis is a register-based study of 704 primary care patients referred electively to cardiology specialists in the city of Turku, Finland, during the year 2016. The patient's medical history, cardiovascular medication use, risk factors, cardiac symptoms, diagnostic tests applied, and diagnoses made were gathered from the medical records. The angiography data was derived from the Hospital District of Southwest Finland data pool. ResultsOf the cohort, 120 (17 %) patients had diabetes mellitus. They were on average older (67 vs. 63 years, p = 0.009) and more often females (62 % vs. 38 %, p = 0.042) than the non-diabetic patients. Chest pain or discomfort was the most prevalent symptom in the diabetic patients and a sense of arrhythmia in the non-diabetic subjects. Ischemic heart disease was diagnosed more often in the person with diabetes (15 %) than in the non-diabetic (6 %) patients (p = 0.004). Cardiac arrhythmias were diagnosed in 26 % of the non-diabetic and 20 % of the diabetic subjects (p = 0.021). ConclusionsSymptoms that might indicate heart disease, especially chest pain/discomfort, are common in both the diabetic and the non-diabetic patients in primary care. Several diagnostic tests are applied, possibly not to miss a life-threatening disease. However, many patients do not get a specific diagnosis for their concerns.

Proteomic profiling identifies novel independent relationships between inflammatory proteins and myocardial infarction.

Inflammation has been implicated in the pathogenesis of coronary heart disease, but the relevance and independence of individual inflammatory proteins is uncertain. To examine the relationships between a spectrum of inflammatory proteins and myocardial infarction (MI). A panel of 92 inflammatory proteins was assessed using an OLINK multiplex immunoassay among 432 MI cases (diagnosed < 66 years) and 323 controls. Logistic regression was used to estimate associations between individual proteins and MI, after adjustment for established cardiovascular risk factors and medication use, and stepwise regression to identify proteins with independent effects. Machine learning techniques (Boruta analysis and LASSO regression) and bioinformatic resources were used to examine the concordance of results with those obtained by conventional methods and explore the underlying biological processes to inform the validity of the associations. Among the 92 proteins studied, 62 (67%) had plasma concentrations above the lower limit of detection in at least 50% of samples. Of these, 15 individual proteins were significantly associated with MI after covariate adjustment and correction for multiple testing. Five of these 15 proteins (CDCP1, CD6, IL1-8R1, IL-6, and CXCL1) were independently associated with MI, with up to three-fold higher risks of MI per doubling in plasma concentrations. Findings were further validated using machine learning techniques and biologically focused analyses. This study, demonstrating independent relationships between five inflammatory proteins and MI, provides important novel insights into the inflammatory hypothesis of MI and the potential utility of proteomic analyses in precision medicine.

Clinical Pharmacy Specialist Collaborative Management and Prescription of Diabetes Medications with Cardiovascular Benefit.

Background: Involvement of Clinical Pharmacy Specialists (CPS) in the care of patients with diabetes mellitus (DM) has been demonstrated to be beneficial. Whether this positive impact applies to increased use of cardiovascular risk-reducing medications is less well established. Objective: To determine the association of CPS co-management on the prescription of diabetes medications with proven cardiovascular benefits for patients with DM and established cardiovascular disease in the primary care setting. Methods: This retrospective cohort study evaluated patients in a Veterans Affairs health-system in primary care settings from February 1, 2019, through January 31, 2020. Patients were included if they had type 2 DM treated with at least one medication and had CVD. Patients were grouped into two cohorts for comparison, those with CPS co-management and those without. The primary outcome was the proportion of patients in each group with new prescriptions for empagliflozin or liraglutide initiated during the study timeframe. Results: In total, 8058 patients were found eligible for inclusion in the study. Clinical co-management by a CPS was provided to 2099 patients. Study medications were prescribed, approved, and initiated in 596 patients during the study period, including 391 (18.6%) in the CPS group and 205 (3.4%) in the non-CPS group (P < .001). Conclusion: This study showed CPS involvement is associated with increased prescribing of diabetes medications with proven cardiovascular benefits.

Exercise capacity as a predictor of coronary microvascular dysfunction

Abstract Introduction Exercise capacity (EC) is an important prognostic test in patients with coronary artery disease (CAD). Positron-emission tomography (PET) is an important risk-stratifying tool to tailor management of patients with coronary artery disease. Purpose We aimed to assess EC in predicting positron emission tomography (PET) myocardial perfusion imaging (MPI) derived coronary flow reserve (CFR). Methods Consecutive patients who had clinically indicated PET MPI and EC were included. EC was defined based on peak metabolic equivalents (METS) achieved during exercise stress test. Myocardial blood flow (MBF) in ml/gm/min was obtained from dynamic PET MPI images at rest and peak hyperemia. The coronary flow reserve (CFR) was calculated as the ratio of stress to rest MBF of the left ventricle. Results The study population consisted of 511 patients who underwent PET MPI and EC testing (mean age 56 (±11), 71% male). Cardiovascular risk factors were prevalent (75% hypertensive, 82% dyslipidemic, 43% diabetics, 27% known CAD). Peak METS &amp;gt;6 was achieved in 81% of patients, and the CFR &amp;lt;2 was present in 27%. In multivariable logistic regression models adjusted for age, sex, cardiovascular risk factors (hypertension, diabetes, dyslipidemia) and medication use (angiotensin converting enzyme inhibitor/angiotensin receptor blocker, statins, beta-blockers), patients with peak METS &amp;gt;6 had a statistically significant lower odds of microvascular dysfunction (CFR &amp;lt;2: OR 0.43, 95% CI 0.26–0.71, p=0.001). Assessment of discrimination showed the model with CFR &amp;lt;2 had an incremental improvement of Harrell's C statistic over clinical variables (0.65 vs 0.69, p=0.02). Conclusion Our findings showed exercise capacity was a good predictor of CFR and microvascular coronary health over and above clinical variables. Further studies are needed to assess the prognostic interplay between EC and CFR. Funding Acknowledgement Type of funding sources: None.

Pre- and post-stroke oral antithrombotics and mortality in patients with ischaemic stroke.

Reducing stroke occurrence requires the effective management of cardiovascular and other stroke risk factors. To describe pre- and post-stroke medication use, focusing on antithrombotic therapy and mortality risk, in individuals hospitalised for ischaemic stroke (IS) in the United Kingdom. Using primary care electronic health records from the United Kingdom, we identified patients hospitalised for IS (July 2016-September 2019) and classed them into three groups: atrial fibrillation (AF) diagnosed pre-stroke, AF diagnosed post-stroke, and non-AF stroke (no AF diagnosed pre-/post-stroke). We determined use of cardiovascular medications in the 90 days pre- and post-stroke and calculated mortality rates. There were 3201 hospitalised IS cases: 76.2% non-AF stroke, 15.7% AF pre-stroke, and 8.1% AF post-stroke. Oral anticoagulant (OAC) use increased between the pre- and post-stroke periods as follows: 54.3%-78.7% (AF pre-stroke group), 2.3%-84.8% (AF post-stroke group), and 3.4%-7.3% (non-AF stroke group). Corresponding increases in antiplatelet use were 30.8%-35.4% (AF pre-stroke group) 38.5%-47.5% (AF post-stroke group), and 37.5%-87.3% (non-AF stroke group). Among all IS cases, antihypertensive use increased from 66.8% pre-stroke to 78.8% post-stroke; statin use increased from 49.6%-85.2%. Mortality rates per 100 person-years (95% CI) were 17.30 (14.70-20.35) in the AF pre-stroke group and 9.65 (8.81-10.56) among all other stroke cases. Our findings identify areas for improvement in clinical practice, including optimising the level of OAC prescribing to patients with known AF, which could potentially help reduce the future burden of stroke.

Achievements of primary prevention targets in individuals with high risk of cardiovascular disease: an 8-year follow-up of the Tromsø study.

AimsTo study change over 8 years in cardiovascular risk, achievement of national guideline-based treatment targets of lipids, blood pressure (BP) and smoking in primary prevention of cardiovascular disease (CVD), medication use, and characteristics associated with target achievement among individuals with high CVD risk in a general population.Methods and resultsWe followed 2524 women and men aged 40–79 years with high risk of CVD attending the population-based Tromsø study in 2007–08 (Tromsø6) to their participation in the next survey in 2015–16 (Tromsø7). We used descriptive statistics and regression models to study change in CVD risk and medication use, and characteristics associated with treatment target achievement. In total, 71.4% reported use of BP- and/or lipid-lowering medication at second screening. Overall, CVD risk decreased during follow-up, with a larger decrease among medication users compared with non-users. Treatment target achievement was 31.0% for total cholesterol <5 mmol/L, 27.3% for LDL cholesterol <3 mmol/L, 43.4% for BP <140/90 (<135/85 if diabetes) mmHg, and 85.4% for non-smoking. A total of 9.8% reached all treatment targets combined. Baseline risk factor levels and current medication use had the strongest associations with treatment target achievement.ConclusionWe found an overall improvement in CVD risk factors among high-risk individuals over 8 years. However, guideline-based treatment target achievement was relatively low for all risk factors except smoking. Medication use was the strongest characteristic associated with achieving treatment targets. This study has demonstrated that primary prevention of CVD continues to remain a major challenge.