Vascular Disease Research Articles

Cerebrovascular disease (CVD) influences Alzheimer disease (AD) risk and progression, but the link between vascular disease and AD pathophysiology remains unclear, particularly in midlife when the impact of CVD on AD risk may be strongest. This study examined the relationship of recently validated vascular cognitive impairment (VCI) plasma biomarker concentrations that reflect aspects of blood-brain barrier dysfunction with MRI markers of CVD and AD plasma biomarker concentrations. The study included middle-aged participants from the Offspring Study of Racial and Ethnic Disparities in AD who had MRI and plasma biomarker data available. Biomarker concentrations of vascular endothelial growth factor (VEGF) family members (VEGF-D, placental growth factor [PlGF], and basic fibroblast growth factor [bFGF]) were measured using the Meso Scale Discovery platform. β-Amyloid (Aβ42, Aβ40), phosphorylated tau 181 (p-tau181), astrocytosis (glial fibrillary acidic protein [GFAP]), and neurodegeneration (neurofilament light chain [NfL]) biomarkers were measured with Simoa immunoassays. White matter hyperintensity (WMH) volumes were derived from T2-weighted MRI scans. Bivariate relationships of WMH, Aβ42/Aβ40 ratio, p-tau181, GFAP, and NfL with VEGF biomarkers were tested, and path analyses examined potential causal pathways linking each VEGF biomarker concentration to WMH and GFAP, as well as their downstream associations with tau pathology and neurodegeneration. We analyzed data from 488 participants (mean [SD] age = 54.3 [10.5]; 66.8% women). Higher PlGF levels were associated with older age (R [CI] = 0.25 [0.17-0.33]); greater WMH volume (R [CI] = 0.2 [0.11-0.29]); and higher levels of GFAP (R [CI] = 0.11 [0.02-0.2]), p-tau181 (R [CI] = 0.12 [0.03-0.21]), and NfL (R [CI] = 0.19 [0.1-0.27]). Higher VEGF-D was associated with increased GFAP (R [CI] = 0.11 [0.02-0.19]) and NfL (R [CI] = 0.16 [0.07-0.25]) levels. bFGF concentration was associated with a lower Aβ42/40 ratio (R [CI] = -0.1 [-0.19 to -0.02]) and higher p-tau181 levels (R [CI] = 0.13 [0.04-0.21]). The best fitting path model showed that PlGF had an indirect effect on GFAP levels mediated by WMH. GFAP subsequently had a direct positive effect on p-tau181, which in turn had a positive effect on NfL levels. VEGF-D and bFGF levels also had a positive direct effect on NfL. The findings suggest that permeability of the blood-brain barrier is linked to AD pathophysiology, contributes to cerebrovascular lesions observed on MRI, and is associated with neuroinflammation in middle age.

Abstract Aims/hypothesis Current guidelines recommend use of sodium–glucose cotransporter-2 inhibitors (SGLT2 inhibitors) for kidney protection in people with type 2 diabetes and early-stage chronic kidney disease (CKD) based on a urinary albumin/creatinine ratio (uACR) of ≥3 mg/mmol. However, individuals with a normal uACR or low-level albuminuria were not represented in kidney outcome trials, leaving uncertainty about absolute treatment benefit in this group. To address this gap and support treatment decisions in clinical practice, we developed and validated a model to predict individual-level kidney protection benefit through the use of SGLT2 inhibitors. Methods This observational cohort study used electronic health record data from UK primary care (Clinical Practice Research Datalink, 2013–2020) of adults with type 2 diabetes, eGFR ≥60 ml/min per 1.73 m 2 and uACR <30 mg/mmol, without heart failure or atherosclerotic vascular disease, who were starting treatment with either SGLT2 inhibitors or the comparator drugs dipeptidyl peptidase-4 (DPP4) inhibitors/sulfonylureas. First, we confirmed the real-world applicability of the relative treatment effect from a previous SGLT2 inhibitor trial meta-analysis, using overlap-weighted Cox proportional hazards models. Second, we assessed calibration of the CKD-PC risk score for kidney disease progression (≥50% eGFR decline, end-stage kidney disease or kidney-related death). Third, we integrated the relative treatment effect with the risk score to predict 3 year individual-level absolute risk reductions for SGLT2 inhibitors, and validated the accuracy of predictions vs overlap-weighted estimates based on observed data. Finally, we compared the clinical utility of a model-based treatment strategy with that of the ≥3 mg/mmol albuminuria threshold. Results In 53,096 initiations of SGLT2 inhibitor treatment compared with 88,404 initiations of DPP4 inhibitor/sulfonylurea treatment, there was a 42% lower relative risk of kidney disease progression with SGLT2 inhibitors (HR 0.58; 95% CI 0.48, 0.69), consistent with a previous trial meta-analysis. The CKD-PC risk score did not require recalibration (calibration slope 1.05; 95% CI 0.94, 1.17). The median overall model-predicted absolute risk reduction with SGLT2 inhibitors was 0.37% at 3 years (IQR 0.26–0.55), and showed good calibration (calibration slope 1.10; 95% CI 1.09, 1.12). As an illustration of clinical utility, using the model predictions to target the same proportion of the population ( n =25,303, 17.9%) as the albuminuria threshold would prevent over 10% more events over 3 years (253 vs 228) by identifying a subgroup of 6.7% of individuals with uACR <3 mg/mmol who showed significantly greater absolute risk reduction in response to SGLT2 inhibitor treatment than the remainder with uACR <3 mg/mmol (3.2% vs 1.2% in extended 5 year observational analyses, p =0.05). Conclusions/interpretation A model adapting the international CKD-PC risk score can accurately predict the individual-level kidney protection benefit from treatment with SGLT2 inhibitors in people with type 2 diabetes and no or early-stage CKD. This could guide treatment decisions in clinical practice worldwide and could target treatment more effectively than the ≥3 mg/mmol albuminuria threshold recommended by current international guidelines. Graphical Abstract

Cardiovascular disease is the leading cause of death in patients receiving hemodialysis, yet effective preventive therapies remain limited. Supplementation with n-3 polyunsaturated fatty acids, especially eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), may have cardiovascular benefits in the general population, but efficacy among patients receiving hemodialysis is uncertain. In a double-blind, randomized, placebo-controlled trial conducted at 26 sites in Canada and Australia, we assigned adult patients receiving maintenance hemodialysis to daily supplementation with fish oil (4 g of n-3 polyunsaturated fatty acids [1.6 g of EPA and 0.8 g of DHA]) or corn-oil placebo. The primary end point was a composite of all serious cardiovascular events including sudden and nonsudden cardiac death, fatal and nonfatal myocardial infarction, peripheral vascular disease leading to amputation, and fatal and nonfatal stroke. Secondary end points included extension of the primary end point to include noncardiac causes of death, the individual components of the primary end point, and a first cardiovascular event or death from any cause. Between November 28, 2013, and July 22, 2019, a total of 1228 participants underwent randomization; 610 were assigned to the fish-oil group and 618 to the placebo group. During 3.5 years of follow-up, the rate of serious cardiovascular events was significantly lower in the fish-oil group than in the placebo group (0.31 vs. 0.61 per 1000 patient-days; hazard ratio, 0.57; 95% confidence interval [CI], 0.47 to 0.70; P<0.001). The rate of the extended primary end point that included noncardiac causes of death appeared to be lower in the fish-oil group than in the placebo group, with a hazard ratio of 0.77 (95% CI, 0.65 to 0.90). The hazard ratio for cardiac death was 0.55 (95% CI, 0.40 to 0.75); for fatal and nonfatal myocardial infarction, 0.56 (95% CI, 0.40 to 0.80); for peripheral vascular disease leading to amputation, 0.57 (95% CI, 0.38 to 0.86); for fatal and nonfatal stroke, 0.37 (95% CI, 0.18 to 0.76); and for a first cardiovascular event or death from any cause, 0.73 (95% CI, 0.61 to 0.87). Adherence to the trial regimen and the incidence of adverse events did not differ meaningfully between the groups. The rate of serious cardiovascular events among participants receiving maintenance hemodialysis was lower with daily supplementation with n-3 fatty acids than with placebo. (Supported by the Heart and Stroke Foundation of Canada and others; PISCES ClinicalTrials.gov number, ISRCTN00691795.).

Familial exudative vitreoretinopathy (FEVR) is a genetically heterogeneous retinal vascular disorder. This report describes a novel frizzled class receptor 4 (FZD4) gene mutation (c.977C>T) identified in a FEVR pedigree and highlights its phenotypic variability and clinical management. A neonatal proband was referred for routine RetCam III fundus screening on postnatal day 3. No systemic abnormalities were reported, but retinal abnormalities were detected. Fundus examination revealed asymmetric retinopathy, with a white temporal demarcation line in the right eye and extensive avascular zones with exudative proliferation in the left. Genetic testing confirmed a heterozygous FZD4 mutation (c.977C>T) in the proband and affected family members, consistent with autosomal dominant FEVR. The proband received prophylactic retinal photocoagulation in both eyes and underwent regular ophthalmic follow-up. Family members with mild retinal changes were monitored. At 12 months of age, the proband achieved normal visual acuity with stable retinal status. Adult carriers exhibited only mild peripheral vascular anomalies, suggesting incomplete penetrance and variable expressivity. This case expands the mutation spectrum of FZD4 and underscores the importance of neonatal fundus screening and genetic analysis for early detection of FEVR. Prompt intervention can preserve visual function despite underlying genetic heterogeneity.

Clonal hematopoiesis (CH) is associated with adverse outcomes. We hypothesized that CH (JAK2V617F and CALR) is associated with cancer, vascular disease, and all-cause mortality, even at a variant allele frequency (VAF) <1%. We screened 19,832 individuals from the Danish General Suburban Population Study for JAK2V617F and CALR mutations by digital-droplet PCR. We used Cox regression with hazard ratio (HR) and 95% confidence interval (95%CI), stratified by CH (JAK2V617F and CALR), VAF (<1% vs. ≥1%), mutation type (JAK2V617F or CALR), and JAK2V617F VAF. The HR (95%CI) for any cancer was 1.71 (1.46-2.01) in CH, 1.28 (1.05-1.56) in VAF<1%, 4.35 (3.34-5.66) in VAF≥1%, and higher for JAK2V617F but not CALR. For hematological cancer, the HR (95%CI) was 8.41 (6.44-10.99) in CH, 3.53 (2.35-5.30) in VAF<1%, and 40.01 (28.97-55.26) in VAF≥1%, and also higher for JAK2V617F and CALR. For arterial diseases, the HR (95%CI) was 1.25 (1.03-1.52) in CH, 1.75 (1.18-2.59) in VAF≥1%, and 1.28 (1.05-1.55) in JAK2V617F. The HR for venous disease was only higher in JAK2V617F VAF≥1%. The HR (95%CI) for all-cause mortality was 1.45 (1.19-1.75) in CH, 1.36 (1.10-1.69) in VAF<1%, 1.91 (1.26-2.88) in VAF≥1%, and also higher for JAK2V617F and CALR. The population-attributable risk proportion (95%CI) for myeloproliferative neoplasms (MPNs) was 76.6% (66.8-86.4) in CH, 47.1% (29.6-64.6) in VAF<1%, and 71.0% (59.4-82.6) in VAF≥1%, with a nomogram generated. CH-defined by the JAK2V617F and CALR mutations-was associated with cancer, MPN, all-cause mortality-even with VAF<1%-and vascular diseases at VAF≥1%. These are novel findings, indicating that the JAK2V617F and CALR mutations confer an oncogenic potential with a VAF below the current CH of indeterminate potential definition.

The burden of atherosclerosis may have prognostic implications for patients affected by venous thromboembolism (VTE). We aimed to assess the association of the presence and extent of atherosclerotic disease with long-term clinical outcomes in patients with acute pulmonary embolism (PE). In patients with PE from the Hokusai-VTE trial, we assessed the association between the presence of atherosclerotic disease in multiple (polyvascular disease), one, or no vascular territories (coronary, cerebral, and/or peripheral arteries) and 1-year risk of VTE or PE recurrence, major bleeding, and all-cause death. We used univariable and multivariable Cox regression analysis, with adjustment for relevant comorbidities and anticoagulation modeled as a time-varying covariate. Of 2800 patients, 67 (2.4%) had polyvascular and 357 (12.7%) had single vascular atherosclerotic disease. During 12-month follow-up, recurrent VTE was reported for a total of 356 patients, including 208 PE events. A total of 52 patients had a major bleeding event and 91 deaths were recorded. Polyvascular atherosclerotic disease was strongly associated with VTE (adjusted hazard ratio,1.91 [95% CI, 1.05-3.49]) and PE recurrence (adjusted hazard ratio, 2.06 [95% CI, 1.03-4.16]). Polyvascular and single vascular disease were associated with major bleeding and all-cause death in univariable analysis; however, these associations attenuated after adjustment. The pre-existing burden of atherosclerosis may have prognostic value with respect to secondary prevention in patients who experienced an acute PE. Optimization of overall cardiovascular risk may be considered by management studies in the follow-up of this patient population. URL: www.clinicaltrials.gov; Unique identifier: identifier: NCT00986154.

Blood loss is a critical component of all surgical procedures. Excess blood loss may require blood transfusion and increase the risk of complications after autologous breast reconstruction. Retrospective cohort of 264 consecutive autologous breast reconstruction patients between July 2017 and June 2022. Patients were stratified by reconstruction timing and bilateral vs. unilateral reconstruction. Post-operative hemoglobin reduction and transfusion incidence were the primary outcomes of interest. Average preoperative hemoglobin (12.6g/dl) was equivalent among all groups. Comparing bilateral immediate (n=77) and delayed (n=50) patients, immediate reconstructions had greater postoperative hemoglobin losses (-3.26 vs. -1.98 g/dl, p<0.01) and higher transfusion rates (14% vs. 2.0%, p=0.02). Comparing unilateral immediate (n=99) and delayed (n=38) patients, immediate reconstructions had greater hemoglobin losses (-2.60 vs. -1.41 g/dl, p<0.0001) and higher transfusion rates (12.1% vs 0.0% p=0.03). Using regression analysis controlling for confounding variables and intra-operative resuscitation risk factors for blood transfusion requirement were post mastectomy radiation therapy requirement (OR 10.3, p<0.01) and vascular disease (OR 14.5, p=0.02). Unilateral reconstruction was protective from requiring transfusion (OR 0.20, p=0.03). Increasing BMI was protective, and with each increasing unit of BMI transfusion requirement incidence decreased by 12.3% (p=0.04). Transfusion was not associated with flap thrombosis or flap loss. Compared to immediate autologous breast reconstruction, a staged approach to both unilateral and bilateral patients can help minimize the risk of transfusion requirement. These factors as well as additional modifiable and non-modifiable risk factors should be considered when determining timing of autologous breast reconstruction for a patient.

Introduction Abdominal aortic aneurysms and dissections (AAA/AD) are vascular disorders with high mortality due to aortic ruptures. Critical pathomechanisms involve immune cell infiltration and degradation of the vascular extracellular matrix (ECM). Hyaluronan (HA), a major constituent of the ECM synthesized by three HA synthase isoenzymes (HAS1-3), plays a role in both processes. Specifically, HAS3 is crucially involved in inflammatory conditions. Here, we aimed to elucidate the role of HAS3-derived HA in AAA/AD. Methods Mice double-deficient for apolipoprotein E and Has3 ( Apoe/Has3 -DKO) and littermate controls ( Apoe -KO) were studied in a model of angiotensin II (AngII)-induced AAA/AD. Results Has3 deficiency improved survival in Apoe/Has3 -DKO mice via reducing aortic ruptures. This was associated with decreased monocyte infiltration into the vessel wall. Aortic RNA-Seq analysis indicated disturbed immune cell adhesion and diapedesis. Transfer of Apoe- deficient bone marrow into Apoe/Has3 -DKO mice largely normalized the Apoe/Has3 -DKO phenotype. While gene expression in endothelial cells (ECs) was not affected, AngII-induced upregulation of proinflammatory cytokines, adhesion receptors and the HA receptor CD44 was attenuated in Apoe/Has3- DKO monocytes. This reduced CD44 cell surface expression in Apoe/Has3- double-deficient monocytes, ultimately inhibiting their in vitro transmigration. Discussion Our results show that HAS3 plays a key role in AAA/AD formation and suggest the HAS3/CD44 axis as promising therapeutic target to reduce monocyte recruitment and aortic rupture.

Peripheral artery disease is a severe ischemic vascular pathology without effective pharmacological approaches and improving angiogenesis to recover blood perfusion is a promising therapeutic strategy. Endothelial cells are the primary cell type contributing to angiogenesis in response to ischemia. However, the molecular mechanisms regulating ischemia-induced angiogenesis remain elusive. We used a discovery-driven approach to identify elevated SRSF1 (serine/arginine splicing factor 1) expression in endothelial cells after ischemia. We used loss- and gain-of-function approaches to explore the role of SRSF1 in angiogenesis both in vivo and in vitro. A mouse model of hindlimb ischemia was used to evaluate ischemia-induced angiogenesis. We also investigated the mechanisms through transcriptome, enhanced crosslinking and immunoprecipitation sequencing, RNA pull-down, and chromatin immunoprecipitation-quantitative polymerase chain reaction analysis. Proteomic analyses identified endogenous SRSF1 accumulated in endothelial cells of the ischemic muscle and responded to hypoxia. Mice deficient in endothelial SRSF1 exhibited impaired blood flow recovery and impaired vasculature formation after hindlimb ischemia. Importantly, overexpression of SRSF1 enhanced blood flow recovery and angiogenesis after hindlimb ischemia. SRSF1 overexpression enhanced the angiogenic functions of human endothelial cells, promoting tube formation, sprouting capability, and cell migration, while SRSF1 knockdown suppressed these functions. Mechanistically, SRSF1 modulated the alternative splicing of ATF3 (activating transcription factor 3) by directly binding to ATF3 premRNA, and SRSF1 overexpression elevated full-length ATF3 transcript at the expense of truncated ATF3Δzip2 transcript. ATF3 then bound directly to the KLF2 (Krüppel-like factor 2) promoter, suppressed KLF2 expression and downstream S1PR1 (sphingosine-1-phosphate receptor 1) signaling. Through upregulation of full-length ATF3 and downregulating KLF2-S1PR1 signaling, SRSF1 promoted endothelial tube formation and angiogenesis. In addition, alprostadil, the prostaglandin E1 analog, could activate the SRSF1 signaling to improve endothelial angiogenesis in vitro and in vivo. Our findings identified SRSF1 as a novel regulator of ischemia-induced angiogenesis that enhances endothelial angiogenic functions by regulating the ATF3-KLF2-S1PR1 pathway. These results suggest that modulation of endothelial SRSF1 may represent a promising therapeutic approach for treating ischemic vascular diseases.

Pathological retinal neovascularization, a major cause of blindness, occurs in conditions such as age-related macular degeneration (AMD) and diabetic retinopathy (DR). Microglial activation and chronic neuroinflammation play critical roles in disease progression by promoting vascular permeability and angiogenesis. While anti-VEGF therapies are the current standard of care, their efficacy is limited, requiring frequent intraocular injections and raising concerns about long-term retinal health. Noninvasive transpalpebral electrical stimulation (TpES) has emerged as a potential alternative therapy, but its mechanism and therapeutic impact remain poorly understood. To investigate the therapeutic effects of TpES, we applied daily microcurrent stimulation (300 µA, 20Hz, 4min) in laser-induced choroidal neovascularization (CNV) and streptozotocin (STZ)-induced DR mouse models. Vascular pathology was assessed using fluorescein angiography, optical coherence tomography (OCT), and immunohistochemistry. Mechanistic studies were conducted using primary microglia and human retinal endothelial cells (HREC) to evaluate TpES-induced changes in intracellular calcium ([Ca²⁺]i) signaling, mitochondrial membrane potential, and ATP production. Additionally, human RPE/choroidal explants from healthy, AMD, and DR donors were cultured to assess TpES effects on angiogenesis in healthy and pathological human tissues. TpES significantly reduced vascular leakage (by ~ 30%, p < 0.001) and lesion size in the CNV model (p < 0.05), while also suppressing microglial infiltration and VEGF-A expression. In the DR model, TpES attenuated microaneurysm formation, preserved endothelial tight junctions (in vitro). Mechanistic studies revealed that TpES suppressed ATP-induced microglial activation by reducing mitochondrial membrane potential and intracellular ATP levels, leading to depletion of ER calcium stores and inhibition of proinflammatory and proangiogenic signaling. TpES also directly suppressed endothelial cell migration and tube formation, as well as angiogenic sprouting in human RPE/choroidal explants. These findings establish TpES as a dual-action therapy that mitigates both inflammation and pathological angiogenesis by modulating microglial and endothelial metabolism. Given its noninvasive nature and ability to target key pathways in retinal pathology, TpES represents a promising therapeutic strategy for AMD, DR, and other retinal vascular diseases.

The blood-retina barrier (BRB) protects retinal neuronal function and enables vision. A compromised, leaky BRB is a hallmark of vision-threatening retinal diseases such as diabetic retinopathy (DR) and wet age-related macular degeneration (AMD) that affect millions of persons worldwide. Strategies to enhance BRB integrity hold promise as therapeutic interventions to prevent vision loss. Previous studies identified Netrin-1 (NTN1) as a key regulator of BRB stability and revealed reduced Netrin-1 signaling in DR patients, suggesting that Netrin-1 supplementation could help preserve BRB function and prevent disease progression. Herein, we used inducible genetic NTN1 overexpression to investigate effects on BRB development and maintenance. We show that global NTN1 overexpression converted leaky vessels at the P5 angiogenic front into a non-leaky state. In pathological settings, NTN1 overexpression reinforced BRB integrity in oxygen-induced retinopathy (OIR), improving electroretinogram (ERG) amplitudes and rescued vascular leak in laser-induced choroidal neovascularization (CNV). NTN1 overexpression or Ntn1 knockout minimally and transiently affected retinal angiogenesis. Global Unc5b deletion phenocopied vascular leak observed in Ntn1 deficient retinas, while angiogenesis defects differed between Ntn1 and Unc5b knockouts. These findings establish Netrin-1 as a promising therapeutic target for preventing BRB breakdown in retinal vascular diseases and suggest that reinforcing the Netrin-1/Unc5b signaling pathway may provide a strategy to selectively stabilize the BRB.

Atherosclerosis is a pathophysiological process common to a range of cardiovascular diseases. We reasoned that considering clinical presentations of atherosclerosis across the coronary, peripheral, and cerebrovasculature as a single entity would enhance statistical power to identify rare genetic variation driving pathological processes across multiple vascular beds. We performed an exome-wide association study of atherosclerotic cardiovascular disease in 434 438 UK Biobank participants of European ancestry. We identified rare, predicted damaging variants in HTRA1, SGTB (small glutamine-rich tetratricopeptide repeat co-chaperone beta), and RBM12 to be associated with risk of atherosclerotic cardiovascular disease, independent of known risk factors. Both SGTB and HTRA1 were downregulated in the aorta of patients with coronary artery disease compared with controls. Loss-of-function variants in the RNA-binding protein RBM12 increased the risk of coronary, cerebrovascular, and peripheral vascular diseases to a similar extent. SGTB increased the risk of atherosclerotic cardiovascular disease in the coronary and peripheral circulations but not the cerebrovasculature. While loss-of-function variants in HTRA1 are known to cause monogenic stroke syndromes, we found that damaging missense variants in HTRA1 are associated with increased risk of disease in both the cerebrovascular and coronary circulation. Surprisingly, the increased risk of coronary artery disease was driven predominantly by a single missense variant (p.R227W; minor allele frequency, 0.009). In vitro, the R227W mutant HTRA1 efficiently proteolyzed the disordered substrate casein but not aggregated α-synuclein. In contrast, a stroke risk-raising variant (D320N) could not efficiently process any of the tested substrates. We identified novel genetic variants predisposing to atherosclerotic cardiovascular diseases that act independently of established cardiovascular risk factors. The observed phenotypic and functional heterogeneities between HTRA1 variants suggest that distinct biochemical mechanisms drive HTRA1-related vascular disease in the brain and heart.

Background: Heart failure and vascular diseases remain leading causes of death in the United States. Although mortality declined in the early 2000s, recent years have raised concerns about a resurgence, particularly in certain demographic and geographic groups. Research Question: We investigated whether national mortality trends for heart failure and vascular disease in adults aged ≥55 years have shifted over time and whether these changes vary across demographic and geographic subgroups. Objective: To assess temporal trends in mortality from heart failure and vascular disease among U.S. adults aged ≥55 years from 1999 to 2019 and examine disparities by sex, race, region, and urbanization to inform targeted interventions. Methods: Death certificate data from the CDC WONDER database were analyzed for adults aged ≥55 years with heart failure (ICD-10: I50) and vascular disease (ICD-10: I70–I78) listed as causes of death. Age-adjusted mortality rates (AAMRs) per 100,000 were calculated. Joinpoint regression was used to estimate annual percent changes (APCs) with 95% confidence intervals (CIs). Trends were stratified by demographic and geographic variables. Statistical significance was defined as p &lt; 0.05(*). Results: A total of 264,577 deaths were recorded, most occurring in medical facilities. APCs declined most among women [2001–2012; −6.77* (CI: −7.26 to −6.28)], non-Hispanic Whites [2001–2012; −6.18* (CI: −6.60 to −5.77)], the Midwest [2001–2012; −7.05* (CI: −7.74 to −6.35)], and urban areas [2001–2012; −6.14* (CI: −6.64 to −5.63)]. In contrast, rates rose among men [2012–2019; 1.92* (1.00 to 2.85)], Whites [2012–2019; 1.48* (0.66 to 2.31)], the South [7.68* (0.39 to 15.50)], and urban residents [1.68* (0.72 to 2.64)]. In 2019, AAMRs were highest among men [19.4 (18.96–19.88)], Black individuals [16.0 (15.12–16.89)], the West [17.4 (16.84–18.02)], and rural areas [17.6 (16.94–18.30)]. West Virginia had the highest state-level AAMR [29.5 (28.48–30.57)]. Conclusion: After a decade of decline, mortality from heart failure and vascular disease among U.S. adults aged ≥55 is rising. The increase is most evident in men, White and Black populations, urban centers, and southern and western regions. The concentration of deaths in institutional settings highlights the need for early prevention and expanded outpatient care. Targeted public health strategies are urgently needed to reverse these trends.

Introduction: Peripheral artery disease (PAD) is an escalating health burden with rising incidence in aging populations driven by its strong association with cardiovascular morbidity and mortality. The RNA-binding protein HuR may represent a therapeutic target by regulating thrombosis and vascular inflammation in PAD. Methods: HuR expression was assessed by single-cell RNA sequencing and in peripheral blood mononuclear cells from 977 deeply phenotyped individuals with vascular disease. Carotid and femoral artery ultrasound was used to assess intima-media thickness, maximum wall thickness, and plaque count. Participants were prospectively followed for major adverse cardiovascular events (MACE). Mechanistically, the role of endothelial HuR was investigated through silencing and overexpression, RNA stability assays, and pharmacological inhibition. The HuR-mRNA interactome was defined by iCLIP-seq, RIP-seq, and mRNA-seq. Results: Single-cell analysis revealed elevated HuR expression in vascular endothelium and infiltrated immune cells from Ldlr -/- mice on high-fat diet vs. chow and human carotid plaques. In humans, elevated HuR expression was independently associated with coronary artery disease (OR=2.67, highest vs. lower tertiles), increased C-reactive protein, and greater mean carotid IMT, after adjustment for traditional risk factors (P&lt;0.05). In healthy individuals, baseline HuR levels predicted accelerated subclinical atherosclerosis progression, reflected by increased carotid and femoral plaque number (P&lt;0.001) and higher maxWT increase (P for interaction=0.045). High HuR levels also correlated with greater MACE incidence over a median 48-month follow-up (log-rank P=0.009). Mechanistically, HuR iCLIP-seq, RIP-seq, and transcriptomics in endothelial cells under basal and TNF-α-stimulated conditions revealed multiple HuR binding sites in AUUUA- and UUUU(G/U)-rich 3′UTRs of pro-inflammatory and pro-thrombotic transcripts regulating adhesion, TGFBR signaling, migration, and differentiation. Pharmacological inhibition or siRNA-mediated HuR silencing suppressed endothelial inflammatory gene expression, whereas HuR overexpression alone induced a pro-inflammatory phenotype via stabilization of its mRNA targetome. Expression of HuR target mRNAs strongly correlated with HuR levels in vascular diseases. Conclusion: HuR inhibition poses as a promising therapeutic target in peripheral artery disease by controling the RNA stability of several pro-atherosclerotic genes.

Vascular sites have distinct susceptibility to atherosclerosis and aneurysm, yet the biological underpinning of vascular site-specific disease risk is largely unknown. Vascular tissues have different developmental origins that may influence global chromatin accessibility, and understanding differential chromatin accessibility, gene expression profiles, and gene regulatory networks (GRN) on single cell resolution may give key insight into vascular site-specific disease risk. Here, we performed single cell chromatin accessibility (scATACseq) and gene expression profiling (scRNAseq) of healthy adult mouse vascular tissue from three vascular sites, 1) aortic root and ascending aorta, 2) brachiocephalic and carotid artery, and 3) descending thoracic aorta. Through a comprehensive analysis at single cell resolution, we discovered key regulatory enhancers to not only be cell type, but vascular site specific in vascular smooth muscle (SMC), fibroblasts, and endothelial cells. We identified epigenetic markers of embryonic origin with differential chromatin accessibility of key developmental transcription factors such as Tbx20 , Hand2 , Gata4 , and Hoxb family members and discovered transcription factor motif accessibility to be cell type and vascular site specific. Notably, we found ascending fibroblasts to have distinct epigenomic patterns, highlighting SMAD2/3 function to suggest a differential susceptibility to TGFβ, a finding we confirmed through in vitro culture of primary adventitial fibroblasts. Finally, to understand how vascular site-specific enhancers may regulate human genetic risk for disease, we integrated genome wide association study (GWAS) data for ascending and descending aortic dimension, and through using a distinct base resolution deep learning model to predict variant effect on chromatin accessibility, ChromBPNet, to predict variant effects in SMC, Fibroblasts, and Endothelial cells within ascending aorta, carotid, and descending aorta sites of origin. We reveal that although cell type remains a primary influence on variant effects, vascular site modifies cell type transcription and highlights genomic regions that are enriched for specific TF motif footprints — including MEF2A, SMAD3, and HAND2. This work supports a paradigm that the epigenomic and transcriptomic landscape of vascular cells are cell type and vascular site-specific and that site-specific enhancers govern complex genetic drivers of disease risk.

Background: Previous studies from Western countries have reported associations between environmental temperature and pulmonary embolism (PE), with increased risk in colder seasons. However, large-scale studies have not yet been conducted in East Asia. Research Questions: We hypothesized a U-shaped association between temperature and PE incidence, with temperature sensitivity varying across clinical subgroups, assuming that cold temperatures might also increase PE risk in Japan. Methods: We analyzed data from the Japanese Registry Of All cardiac and vascular Diseases (JROAD)-DPC inpatient database (2012–2021), covering nearly all acute-care hospitalizations in Japan (~6 million/year). A total of 63,354 emergency admissions for acute PE were identified. Mean age was 69 ± 16 years; 42% male, 17% with cancer, 13% with diabetes, 16% with dyslipidemia, and 30% with hypertension. Weather data (mean/max/min temperature, humidity, pressure, sunshine, wind) were obtained from the Japan Meteorological Agency and linked to admission dates by region. Univariable and multivariable logistic regression were used to evaluate associations between PE risk and meteorological factors. Subgroup analyses were conducted for season, temperature shocks (≥5°C change in 24h), extreme days (≥30°C or ≤0°C), and cancer or shock status. PE incidence per 10 million population was calculated using prefectural population data, and cubic spline models were used to visualize the temperature–PE relationship. Results: Lower mean temperature (OR 1.02 per 1°C decrease; 95% CI 1.01–1.03), cold shock (OR 1.05; 95% CI 1.02–1.08), and hot shock (OR 1.04; 95% CI 1.01–1.07) were associated with increased PE risk. In winter, lower temperatures increased PE risk (min temp OR 1.009; p&lt;0.001); in spring, higher temperatures were linked to increased risk (min temp OR 1.025; p&lt;0.001). Hot days (OR 1.13; 95% CI 1.05–1.22) and cold days (OR 0.87; 95% CI 0.81–0.94) were also significantly associated with PE. Spline analysis confirmed a U-shaped association, with lowest risk at ~20°C. Patients without cancer or shock were more temperature-sensitive, while those with cancer or shock had persistently high PE incidence year-round. Conclusion: This nationwide study in Japan identified a U-shaped association between temperature and PE incidence. Patients without cancer or shock showed clear weather sensitivity, whereas those with cancer had elevated year-round risk.

Background: Atrial fibrillation (AF) is the most common arrhythmia worldwide and is associated with significant morbidity, mortality, and healthcare spending. Despite medical advances, AF remains underdiagnosed and undertreated, leading to preventable complications. FibriCheck © [Qompium NV, Hasselt, Belgium] is a medical analysis platform that uses an end-to-end algorithm to detect AF based on photoplethysmography (PPG) signals recorded on consumer smartphones. Purpose: The study aimed to validate FibriCheck in a large, multi-center and multi-national cohort on ten popular smartphone devices. Methods: A total of 236 patients were recruited from five independent, large academic centers in the United States and Europe. The FibriCheck system incorporates several convolutional neural networks to detect individual heartbeats, estimate average heart rate, and classify the rhythm based on PPG signals. Classification is verified by a FibriCheck technician. Classification performance was compared to the standard 12-lead electrocardiogram in the study population. Performance was assessed across clinical subgroups and smartphone devices. Results: FibriCheck demonstrated high overall accuracy and reliability in detecting AF without technician verification: accuracy 98.5% (95% CI: 98.0%-99.0%); sensitivity 96.3% (95% CI: 94.4%-97.7%); specificity 99.3% (95% CI: 98.8%-99.7%); positive predictive value 98.0% (95% CI: 96.5%-98.9%); negative predictive value 99.8% (95% CI: 99.6%-99.9%). Performance was not affected by smartphone device or the presence or absence of comorbid heart failure, vascular disease, hypertension, diabetes, or stroke. Sensitivity was reduced in those with darker skin tone and higher BMI, but this was mitigated by technician verification. Conclusions: The study confirms the high accuracy, sensitivity, and specificity of the FibriCheck algorithm in detecting AF across various smartphone models and clinical subgroups. These findings support the use of FibriCheck as a reliable, low-cost, and easily accessible tool for AF detection in a diverse patient population.

Introduction: Despite therapeutic advances, atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of death in industrialized nations, highlighting the need for precision medicine. ADAR1-mediated RNA editing has emerged as a key regulator in vascular disease, yet its interaction with the RNA-binding protein HuR, potentially governing Cathepsin expression, remains poorly understood. Methods: Mechanistic insights into ADAR1-mediated Alu A-to-I RNA editing and its interplay with HuR were derived from RNA sequencing, editing analyses, gain- and loss-of-function studies, stability assays, HuR iCLIP, luciferase reporter assays, and RIP following ADAR1 siRNA-mediated knockdown in primary human endothelial cells. CTSK and ADAR1 expression was quantified by qRT-PCR in peripheral blood mononuclear cells (n=367) and carotid plaques (n=35) from individuals with and without ASCVD. Subclinical atherosclerosis and its progression were assessed by ultrasound and prospectively followed for MACE. Results: Endothelial mRNA sequencing identified two significantly downregulated Cathepsins upon ADAR1 knockdown, including CTSK, a protease linked to atherosclerotic plaque progession and instability. CTSK was extensively edited within Alu regions in intron 5. Silencing of ADAR1 led to a twofold decrease in mature CTSK mRNA and accumulation of pre-mRNA, while overexpression reversed this. HuR binding motifs were near editing sites, and HuR knockdown or overexpression mirrored ADAR1 effects on CTSK processing. Actinomycin D treatment confirmed that knockdown of either ADAR1 or HuR reduced CTSK mRNA stability. Luciferase, iCLIP, and RIP assays confirmed HuR’s interaction with intronic edited CTSK regions—lost without editing (all P &lt; 0.05). Clinically, CTSK expression strongly correlated with ADAR1 and HuR levels in ASCVD patients (r = 0.71 and 0.82, P &lt; 0.001) and plaques (r = 0.81 and 0.86, P &lt; 0.001). CTSK expression was independently associated with ASCVD (OR = 1.84, highest vs. lower tertiles), elevated C-reactive protein (&gt;3 mg/dL), increased carotid maximum wall thickness (&gt;1.39 mm; OR = 4.44), and multivessel disease (OR = 4.09) (all P &lt; 0.05). Elevated CTSK also predicted accelerated subclinical atherosclerosis progression and higher MACE incidence over 48 months. Conclusion: Intronic Alu -mediated RNA editing modulates HuR-dependent pre-mRNA processing, revealing a novel regulatory layer in ASCVD with implications for precision medicine.

Introduction: Standard cardiovascular testing relies primarily on medical history and coronary imaging, which may fail to detect the full extent of systemic vascular disease. Using AI in non-coronary vascular blood vessel areas, such as the carotid, aortic, and peripheral systems, may offer a thorough investigation and provide a better understanding of one's risk. Currently, manual assessments require a significant amount of time, and the varying interpretations of different experts often influence their accuracy. Hypothesis: Applying AI to the automated analysis of imaging for vascular diseases across multiple territories yields more accurate predictions of major adverse cardiovascular events than traditional risk scores and image analysis from a single area. Methods: Using PRISMA standards, we searched a range of databases (from 2018 to 2024) for studies focused on AI algorithms in non-coronary vascular imaging. Two researchers evaluated the studies and pulled out the information on predicting cardiovascular death, heart attack and stroke. Secondary outcomes included measuring the frequency with which each test produces the same result, assessing the time required for processing, and evaluating how well they correlate with established vascular biomarkers. A review of study quality was conducted using the QUADAS-2 and NOS. Results: All 23 selected studies (n = 28,894) found that AI-enhanced analysis of vascular parameters consistently predicted risk more accurately than traditional risk scales. Measurements of carotid thickness and stiffness of the aorta and arteries of the legs were highly reproducible and required much less analysis time using automation. Authors across various studies found that models using data from multiple areas performed better than models trained solely on one area. Conclusion: This analysis demonstrates that AI features in the automated analysis of imaging from multiple locations outside the heart enhance both the accuracy and efficiency of cardiovascular risk estimation. It enables thorough surveying of the vascular system for precision cardiology.

Background: Patients undergoing maintenance hemodialysis (HD) are at increased risk of infective endocarditis (IE), but current data regarding their clinical profiles and outcomes remain limited. We aimed to evaluate the clinical characteristics, treatment patterns, and in-hospital outcomes of IE in HD patients using a nationwide database. Methods: We analyzed data from the Japanese Registry of All Cardiac and Vascular Diseases–Diagnosis Procedure Combination (JROAD-DPC) between April 2018 and March 2021. Adult IE patients who received antibiotics and underwent echocardiography were included. HD patients were identified using diagnosis codes for end-stage renal disease. Clinical and institutional characteristics, in-hospital mortality, complications, and cardiac surgery rates were compared between HD and non-HD patients. Predictors of in-hospital death in HD patients were assessed using multivariable mixed-effects logistic regression. Results: Of 12,158 IE patients, 806 (6.6%) were on maintenance HD. Compared with non-HD patients, HD patients were older (71.1 vs 68.8 years), had lower Barthel Index scores, and higher rates of diabetes (35.5% vs 18.2%) and peripheral vascular disease (6.6% vs 3.9%) (all p&lt;0.05). Cardiac predisposing conditions such as atrial fibrillation and valvular disease were less common in the HD group. In-hospital mortality was significantly higher in HD patients (30.0% vs 13.5%, p&lt;0.05), and they experienced more cerebrovascular complications (33.6% vs 29.0%). Cardiac surgery was performed less frequently in the HD group (23.4% vs 29.2%, p&lt;0.05). Among HD patients, independent predictors of in-hospital death included older age (OR 1.45), impaired activities of daily living (non-full Barthel Index; OR 0.54), peripheral vascular disease (OR 3.31), and cerebrovascular complications (OR 1.73). Hospitals with higher cardiac surgery volumes were associated with lower mortality and higher surgical intervention rates among HD patients. Conclusions: HD patients with IE had worse in-hospital outcomes, including higher mortality and complications, and were less likely to undergo surgery despite potential benefits. However, treatment at high-volume surgical centers was associated with improved outcomes. These findings highlight the need for optimized multidisciplinary care and referral strategies in this high-risk population.