bluuebunny/crossref_metadata_2025 huggingface dataset:
Long-term effects of an intensive prevention program (IPP) after acute myocardial infarction – the IPP Follow-up and Prevention Boost Trial
Authors: Wienbergen H , Fach A , Meyer S , Schmucker J , Osteresch R , Michel S , Retzlaff T , Steckenborn M , Elsaesser A , Langer H , Hambrecht R
Published: November 2020

Background

The effects of an intensive prevention program (IPP) for 12 months following 3-week rehabilitation after myocardial infarction (MI) have been proven by the randomized IPP trial. The present study investigates if the effects of IPP persist one year after termination of the program and if a reintervention after >24 months (“prevention boost”) is effective.

Methods

In the IPP trial patients were recruited during hospitalization for acute MI and randomly assigned to IPP versus usual care (UC) one month after discharge (after 3-week rehabilitation). IPP was coordinated by non-physician prevention assistants and included intensive group education sessions, telephone calls, telemetric and clinical control of risk factors. Primary study endpoint was the IPP Prevention Score, a sum score evaluating six major risk factors. The score ranges from 0 to 15 points, with a score of 15 points indicating best risk factor control.

In the present study the effects of IPP were investigated after 24 months – one year after termination of the program. Thereafter, patients of the IPP study arm with at least one insufficiently controlled risk factor were randomly assigned to a 2-months reintervention (“prevention boost”) vs. no reintervention.

Results

At long-term follow-up after 24 months, 129 patients of the IPP study arm were compared to 136 patients of the UC study arm. IPP was associated with a significantly better risk factor control compared to UC at 24 months (IPP Prevention Score 10.9±2.3 points in the IPP group vs. 9.4±2.3 points in the UC group, p<0.01). However, in the IPP group a decrease of risk factor control was observed at the 24-months visit compared to the 12-months visit at the end of the prevention program (IPP Prevention Score 10.9±2.3 points at 24 months vs. 11.6±2.2 points at 12 months, p<0.05, Figure 1).

A 2-months reintervention (“prevention boost”) was effective to improve risk factor control during long-term course: IPP Prevention Score increased from 10.5±2.1 points to 10.7±1.9 points in the reintervention group, while it decreased from 10.5±2.1 points to 9.7±2.1 points in the group without reintervention (p<0.05 between the groups, Figure 1).

Conclusions

IPP was associated with a better risk factor control compared to UC during 24 months; however, a deterioration of risk factors after termination of IPP suggests that even a 12-months prevention program is not long enough. The effects of a short reintervention after >24 months (“prevention boost”) indicate the need for prevention concepts that are based on repetitive personal contacts during long-term course after coronary events.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Stiftung Bremer Herzen (Bremen Heart Foundation)
Individuals with familial hypercholesterolemia have increased risk of re-hospitalization after acute myocardial infarction compared with controls
Authors: Svendsen K , Krogh H.W , Igland J , Tell G.S , Mundal L.J , Holven K.B , Bogsrud M.P , Leren T , Retterstol K
Published: November 2020

Background and aim

We have previously reported that individuals with familial hypercholesterolemia (FH) have a two-fold increased risk of acute myocardial infarction (AMI) compared with the general population. The consequences of having an AMI on re-hospitalization and mortality are however less known. The aim of the present study was to compare the risk of re-hospitalization with AMI and CHD and risk of mortality after incident (first) AMI-hospitalization between persons with and without FH (controls).

Methods

The original study population comprised 5691 persons diagnosed with FH during 1992–2014 and 119511 age and sex matched controls randomly selected from the general Norwegian population. We identified 221 individuals with FH and 1947 controls with an incident AMI registered in the Norwegian Patient Registry (NPR) or the Cardiovascular Disease in Norway Project during 2001–2017. Persons with incident AMI were followed until December 31st 2017 for re-hospitalization with AMI or coronary heart disease (CHD) registered in the NPR, and for mortality through linkage to the Norwegian Cause of Death Registry. Risk of re-hospitalization was compared with sub-hazard ratios (SHR) from competing risk regression with death as competing event, and mortality was compared using hazard ratios (HR) from Cox regression. All models were adjusted for age.

Results

Risk of re-hospitalization was 2-fold increased both for AMI [SHR=2.53 (95% CI: 1.88–3.41)] and CHD [SHR=1.82 (95% CI: 1.44–2.28)]. However, persons with FH did not have increased 28-day mortality following an incident AMI (HR=1.05 (95% CI: 0.62–1.78), but the longer-term (>28 days) mortality after first AMI was increased in FH [HR=1.45 (95% CI: 1.07–1.95].

Conclusion

This study yields the important finding that persons with FH have increased risk of re-hospitalization of both AMI and CHD after incident AMI. These findings call for more intensive follow-up of individuals with FH after an AMI.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): University of Oslo and Oslo University Hospital
Successful lifestyle modification in older patients with coronary artery disease: results from the RESPONSE-2 trial
Authors: Jepma P , Jorstad H.T , Snaterse M , Ter Riet G , Kragten J.A , Lachman S , Minneboo M , Boekholdt S.M , Peters R.J.G , Scholte Op Reimer W.J.M
Published: November 2020

Introduction

Interventions to reduce lifestyle-related risk factors (LRFs) such as overweight, physical inactivity and smoking are effective in the secondary prevention of cardiovascular events. However, evidence of the effects of lifestyle-related secondary prevention programmes in older patients with coronary artery disease (CAD) is less conclusive than in younger patients.

Purpose

To compare the treatment effect on lifestyle-related risk factors (LRFs) in older (≥65 years) versus younger (<65 years) patients with CAD in The Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists 2 (RESPONSE-2) trial.

Methods

The RESPONSE-2 trial was a community-based lifestyle intervention trial (N=824) comparing nurse-coordinated referral to a comprehensive set of three lifestyle interventions (physical activity, weight reduction and/or smoking cessation) to care as usual. The primary outcome was the proportion of patients with improvement at 12 months follow-up (N=711) in at least 1 LRF (without deterioration in the other LRFs). In the current analysis, we assessed if the overall beneficial treatment effect of the RESPONSE-2 intervention varied by age.

Results

At baseline, older patients (n=245, 69.2±3.9) had significantly more serious cardiovascular risk profiles and comorbidities (hypertension, diabetes mellitus and peripheral artery disease) than younger patients (n=579, 53.7±3.9). The overall treatment effect did not vary by age (OR overall 1.67, 95% CI 1.22 - 2.31). However, older patients were more likely to achieve ≥5% weight loss (OR old 5.58, 95% CI 2.77–11.26 vs. OR young 1.57, 95% CI 0.98 - 2.49, P interaction=0.003) and younger patients were more likely to show non-improved individual LRFs (OR old 0.38, 95% CI 0.22–0.67 vs. OR young 0.88, 95% CI 0.61–1.26, P interaction=0.01).

Conclusion

Despite more serious cardiovascular risk profiles and comorbidities among older patients, nurse-coordinated referral to community-based lifestyle interventions was at least as successful in improving LRFs in older as in younger patients. Higher age alone should not be a reason to withhold lifestyle interventions in patients with CAD.

LRFs at 12 months follow-up

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): The RESPONSE-2 trial was sponsored by Weight Watchers International, Inc. (New York, New York) and Philips Consumer Lifestyle (the Netherlands). This work was also supported by the Netherlands Organisation for Scientific Research (NWO) to PJ.
Effect of caloric restriction and statins on the process of cholesterol transfer to HDL in women with premature CAD
Authors: Leal D.P , Tavoni T.M , Kawabara K.L , Faria N.F.O , Nascimento J.R.O , Cesar L.A.M , Strunz C.M.C , Mansur A.D.P
Published: November 2020

Introduction

Transfer of cholesterol to HDL from the other lipoprotein classes has an important role in HDL metabolism and function. Patients with premature CAD showed reduced rates of cholesterol transfer, which was not dependent on HDL-cholesterol levels. The effects of statin treatment and caloric restriction on anti-atherogenic properties of HDL, which are critical issues in CAD prevention, have been scarcely described.

Purpose

To evaluate the effect of caloric restriction associated or not with statin use on the transfer of cholesterol to HDL.

Methods

This randomized study analyzed the functionality of HDL in 26 women, aged ≤55 years, with CAD diagnosed angiographically. Patients were allocated in two groups: caloric restriction (CR) group (n=13) characterized by a diet that reduced 30% of their usual daily caloric intake, and CR plus atorvastatin (CR+A) group (n=13) characterized by the addition of 80 mg of atorvastatin daily to the CR diet. Blood samples were collected before and 60 days after starting interventions for analysis of lipid profile that included apoA-I and B, and to evaluate the anti-atherogenic functionality of HDL by the cholesterol transfer to HDL assay performed in vitro, using artificial donor lipid nanoparticles resembling lipoproteins labeled with radioactive lipids and incubated with total plasma.

Results

Body mass index reduced in both groups (p<0.01). In the CR group, we observed a tendency of reduction of total cholesterol from 229±55 to 207±59 mg/dL (p=0.07), LDL-C from 143±40 to 129±49 mg/dL (p=0.07) and HDL-C 56±13 to 53±14 mg/dL (p=0.07). Apo B and apo A-I reduced, respectively, from 1.20±0.35 to 1.05±0.36 g/L (p=0.01) and 1.59±0.32 to 1.43±0.28 g/L (p=0.01). In the CR+A group, we observed reduction of total cholesterol from 253±97 to 169±47 mg/dL (p<0.01), LDL-C from 147±57 to 97±39 mg/dL (p<0.01), and apo B from 1.26±0.39 to 0.85±0.22 g/L (p<0.01). HDL-C and apo A-I did not change. In CR group, the transfers of unesterified and esterified cholesterol to HDL did not change. In CR+A group, the percentage of transfer of unesterified cholesterol to HDL increased by almost 10%, from 3.4±0.6% to 3.7±0.7% (p=0.03), but no change in esterified cholesterol transfer.

Conclusion

CR and atorvastatin treatment was not only beneficial because of LDL-C lowering but also by increasing the transfer of unesterified cholesterol to the HDL fraction, an independent anti-atherogenic mechanism, that may be important in the treatment of women with premature CAD.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001
Risk for recurrent cardiovascular events and expected risk reduction with optimal treatment one year after an acute coronary syndrome
Authors: Zafeiropoulos S , Farmakis I.T , Kartas A , Arvanitaki A , Pagiantza A , Boulmpou A , Tampaki A , Kosmidis D , Nevras V , Markidis E , Papadimitriou I , Arvanitakis K , Ziakas A , Karvounis H , Giannakoulas G
Published: November 2020

Background

According to the latest ESC Guidelines for chronic coronary syndromes (CCS), patients who suffered an acute coronary syndrome (ACS) pass to a chronic stable phase after one year. In these patients the estimated 10-year risk for recurrent cardiovascular (CV) events varies considerably. We estimated this risk and the expected risk reduction after optimal control.

Methods

We applied the SMART risk score in 211 patients one year after an ACS to estimate the 10-year risk for recurrent CV events (subsequent non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death). We assessed the distribution of the estimated risk and the potential risk reduction that might be achieved with an optimal guideline-directed management of modifiable risk factors (systolic blood pressure, low-density lipoprotein cholesterol, smoking and body mass index).

Results

In our cohort, the median SMART score was 16% [interquartile range (IQR), 9.5–26]. If all modifiable risk factors met guideline-recommended targets, median SMART risk score would be 9.4% (IQR, 5.9–17.1), with 52% of the patients at a 10-year risk <10%, while 10% and 11% at 20–30% and >30% risk respectively. The total median reducible risk was 4.7% (IQR, 1.7–8.8).

Conclusions

The SMART score had a wide distribution among patients with CCS. Noteworthy, one out of five patients will remain at a >20% 10-year risk, even with optimal risk factors management, clearly underlining that residual risk is an unmet clinical issue, which demands individualized patient care.

Baseline and total residual risk score

Funding Acknowledgement

Type of funding source: None
Guideline adherence is associated with long-term all-cause mortality in patients after an acute coronary syndrome
Authors: Farmakis I.T , Zafeiropoulos S , Pagiantza A , Boulmpou A , Arvanitaki A , Nevras V , Tampaki A , Markidis E , Papadimitriou I , Karvounis H , Giannakoulas G
Published: November 2020

Background/Introduction

Guideline-directed medical therapy (GDMT) remains the mainstay in the long-term management of patients after an acute coronary syndrome (ACS). Data on the association of adherence to GDMT with clinical outcomes are scarce.

Purpose

To assess the adherence to GDMT and its relation to all-cause mortality in a population of patients after an ACS.

Methods

In this post-hoc analysis of the prospective, randomised IDEAL-LDL trial (NCT02927808) we analyzed data of 360 ACS patients discharged from a cardiology clinic. Median follow-up period was 35.9 (IQR 25.7–41.6) months. GDMT was assessed at discharge and at the 1-year follow-up, at which time data was collected by telephone interviews or ambulant visits. GDMT was defined as compliance with secondary prevention therapies (statin, antiplatelet, b-blocker, angiotensin-converting enzyme inhibitor (ACE-i) or angiotensin II receptor blocker (ARB)), as per their respective indication in the 2017 STEMI and 2015 NSTE-ACS ESC Guidelines. Extended follow-up data for mortality was collected from the national health insurance electronic prescription system.

Results

Median age of the entire cohort was 60 (IQR-53–71) years, 18.6% were female and 55.6% suffered a STEMI. At discharge, 342 patients (95%) received statins, 331 (91.9%) proper antithrombotic therapy (86.4% on dual antiplatelet therapy (DAPT), 2.5% on antiplatelet plus anticoagulant and 3% on triple therapy), 309 (85.8%) β-blockers and 217 (60.3%) ACE-i or ARB. GDMT at discharge was prescribed to 272 (75.6%) patients. The 1-year mortality rate was 4.7% (IQR, 2.5–6.9) and there was no mortality benefit for GDMT (HR=0.77 95% CI 0.27 - 2.2) (Figure 1a). At the one-year follow up, 323 (94.2%) of 343 alive patients received statin treatment (72.4% of which a high-intensity statin), 330 (96.2%) any antithrombotic therapy (59.8% on DAPT, 5.2% on any anticoagulant), 263 (76.7%) a β-blocker and 194 (56.6%) an ACE-I or ARB. GDMT at one-year follow up was prescribed to 248 (72.3%) patients. Beyond one year, all-cause mortality was significantly reduced in patients receiving GDMT adjusted for age, STEMI, revascularization with percutaneous coronary angioplasty, history of diabetes mellitus and arterial hypertension. (1.6% vs 9.5%, aHR 0.3 95% CI 0.08 - 0.92) (Figure 1b).

Conclusions

Adherence to GDMT remains stable one year after an ACS. GDMT was associated with a significant decrease in long-term mortality, but not associated with one-year mortality.

Figure 1. GDMT at baseline, at 1 year and mortality

Funding Acknowledgement

Type of funding source: None
What is the potential cardiovascular risk reduction associated with achieving LDL-C levels recommended in the ESC/EAS guidelines for very high-risk patients? Data from 18 European countries
Authors: Ray K.K , Bray S , Catapano A.L , Poulter N , Villa G
Published: November 2020

Background/Introduction

For patients at very-high risk of cardiovascular (CV) events, the 2016 ESC/EAS dyslipidaemia guidelines recommended lipid-lowering therapy (LLT) to achieve an LDL-C level below 70 mg/dL. This was lowered to an LDL-C level below 55 mg/dL in the 2019 guidelines.

Purpose

To assess: 1) the risk profile of European patients with established atherosclerotic CV disease (ASCVD) receiving LLT; and 2) the treatment gap between the estimated risk and the population benefits if all patients were to achieve LDL-C levels of 70 mg/dL and 55 mg/dL.

Methods

We used data from Da Vinci, an observational cross-sectional study conducted across 18 European countries. Data were collected at a single visit between June 2017 and November 2018, for consented adults who had received any LLT in the prior 12 months and had an LDL-C measurement in the prior 14 months. LDL-C level was assessed at least 28 days after starting the most recent LLT (stabilised LLT). For each patient with established ASCVD receiving stabilised LLT, we: 1) calculated their absolute LDL-C reduction required to achieve LDL-C levels of 70 mg/dL and 55 mg/dL; 2) predicted their 10-year CV risk using the REACH score based on demographic and medical history; 3) simulated their relative risk reduction (RRR) by randomly sampling from the probability distribution of the rate ratio per 38.7 mg/dL (1 mmol/L) estimated by the Cholesterol Treatment Trialists Collaboration meta-analysis; and 4) calculated their absolute risk reduction (ARR) achieved by meeting LDL-C levels of 70 mg/dL and 55 mg/dL.

Results

A total of 2039 patients with established ASCVD were included in the analysis. Mean (SD) LDL-C was 83.1 (35.2) mg/dL. 40.4% and 19.3% of patients achieved LDL-C levels of 70 mg/dL and 55 mg/dL, respectively. Mean (SD) 10-year CV risk calculated using the REACH score was 36.3% (15.4%). Mean absolute LDL-C reductions of 19.6 mg/dL and 30.4 mg/dL were needed to reach LDL-C levels of 70 mg/dL and 55 mg/dL, respectively. When adjusted for the LDL-C reduction required to achieve an LDL-C level of 70 mg/dL, mean ARR was 3.0%, leaving a mean (SD) residual 10-year CV risk of 33.3% (15.5%). When adjusted for the LDL-C reduction required to achieve an LDL-C level of 55 mg/dL, mean ARR was 4.6%, leaving a mean (SD) residual 10-year CV risk of 31.7% (15.2%).

Conclusion(s)

In a contemporary European cohort with ASCVD receiving LLT, the 10-year risk of CV events is high and many patients do not achieve LDL-C levels of 55 mg/dL or even of 70 mg/dL. Moreover, even if all patients were to achieve recommended LDL-C levels, they would still remain at a high residual risk of CV events. These data suggest these patients require even more intensive LLT.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Amgen
How do physicians of different specialties assess smoking status in hospital and primary care
Authors: Bondar S , Konradi A , Salagay O
Published: November 2020

Background

Assessment of current smoking status and history of smoking is critically important for risk stratification and initiation of smoking cessation interventions. However, assessment of smoking status it not included in quality of care measurement, thus the information can be frequently missed in patient' records.

Purpose

To investigate how careful smoking status is recorded in hospital and primary care by physicians of different specialties.

Methods

Electronic records from 124097 hospital and primary care adult patients' case histories were analyzed. Records were made by physicians of different specialties in 2018 and reflected all database for one year form big national medical research Centre.

Results

Smoking status was assessed and recorded only in 33504 of all 124097 (27.0%) electronic records, in 4056 of 44007 (9.2%) hospital records and in 29448 of 80090 (36.8%) out-patient episodes (p<0.001). The highest smoking status assessment rate was observed in nephrologists – 284 of 508 (55.9%), oncologists – 82 of 151 (54.3%), gynecologists – 4085 of 8147 (50.1%), cardiologists – 19591 of 40366 (48.5%) and hematologists – 2310 of 4891 (47.2%). The lowest smoking status recording rate was documented in surgery: cardiac surgeons – 243 of 4843 (5.0%), neurosurgeons – 449 of 10161 (4.4%), urologists – 24 of 1686 (1.4%), as well as by ophthalmologists – 5 of 3152 (0.2%). Radiologists, dermatologists, otolaryngologists, genetics and dentists did not include any records of smoking status at all. 72799 (58.7%) of assesses patients were women. Smoking status was more frequently recorded in women – 20780 of 72799 (28.5%) than in men – 12724 of 51298 (24.8%) (p<0.001), and in young patients more often than in elderly patients, thus the reported smoking rate was maximal in the age group of 20–29 years. Among those records, where the status was assessed, smoking was more prevalent among men – 3746 of 12724 (29.4%) compared women – 1901 of 20780 (9.1%).

Conclusions

Smoking status and ex-smoking are indicated in medical records in less than one third of cases, especially low rate was observed in hospital records. No attention to smoking can influence correct risk assessment and lack of advice for smoking cessation. Even cardiologists indicate smoking status in less than 50% of patients' visits. Significant efforts should be made to emphasize the importance of risk factor assessment with a special attention to smoking as a potentially modifiable risk factor in order to decrease mortality and morbidity in Russia.

Funding Acknowledgement

Type of funding source: None
Cardiovascular risk of smoking in patients without obstructive coronary artery disease
Authors: Olesen K.K.W , Thrane P.G , Thim T , Wurtz M , Kristensen S.D , Maeng M
Published: November 2020

Background

Smoking increases risk of cardiovascular disease by increasing atherosclerosis and thrombogenesis.

Purpose

We examined the impact of smoking on cardiovascular risk in patients without obstructive coronary artery disease (CAD) after coronary angiography.

Methods

We conducted a cohort study in patients without obstructive CAD examined by coronary angiography from 2003–2016 in Western Denmark and no previous history of MI or coronary revascularization. Smokers were compared with non-smokers (former/never smokers) and with an age- and sex matched comparison group sampled from the Western Denmark general population without a history of CAD. The main outcome was myocardial infarction (MI). Other outcomes were ischemic stroke and death. Maximum follow-up was 10 years. Adjusted hazards ratios (aHRs) were estimated using Cox regression.

Results

We identified 46,462 patients without obstructive CAD, of whom 10,879 (23%) were active smokers and 35,583 (77%) were non-smokers at the time of angiography. Patients were matched with 234,648 individuals from the general population with no previous MI or coronary revascularization. Median follow-up was 7.0 years. Smokers had higher risks of MI (aHR 1.65, 95% CI: 1.41–1.93), ischemic stroke (aHR 1.49, 95% CI: 1.28–1.74), and death (aHR 1.77, 95% CI: 1.67–1.87) compared to non-smokers undergoing CAG. As shown in the Figure, the MI risk increased immediately after start follow-up and the curves continued to diverge. Compared to the general population, smokers without obstructive CAD had a similar risk of MI (aHR 0.96, 95% CI: 0.83–1.10), but an increased risk of ischemic stroke (aHR 1.36, 95% CI: 1.19–1.56) and death (aHR 1.49, 95% CI: 1.41–1.56), while non-smokers had reduced risks of MI (aHR 0.57, 95% CI: 0.51–0.63), ischemic stroke (aHR 0.85, 95% CI: 0.78–0.93), and death (aHR 0.78, 95% CI: 0.75–0.81).

Conclusions

In patients without obstructive CAD by coronary angiography, active smoking was associated with a 65% increased 10-year risk of MI compared to non-smokers, suggesting a prothrombotic effect of smoking. Compared to a general population, with unknown CAD and smoking status, smokers examined by CAG had a similar or higher risk of cardiovascular events despite the absence of CAD, while non-smokers had a lower risk.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital
The association between late-adolescent smoking and long-term mortality: a dose-response relationship
Authors: Tiosano S , Afek A , Fink N , Avramovich E , Derazne E , Tzur D , Twig G
Published: November 2020

Introduction

Tobacco smoking has detrimental medical effects. However, whether late-adolescence tobacco smoking increases early mortality risk is unclear. The aim of our study was to determine the association between tobacco smoking among Israeli adolescents and mortality in young adulthood.

Methods

The Israeli Defense Forces (IDF) health survey enrolls annually random sample of 3–5% of IDF recruits who voluntarily report lifestyle and tobacco consumption habits (up to 10 cigarettes a day were defined as light smokers, 10–20 cigarettes a day and above 20 cigarettes a day as medium and heavy smokers respectively). Medical and sociodemographic variables (education, residential socioeconomic status, country of birth or origin) were included. Included in this study were 62,134 soldiers (56% men; average age 17.3 years) who enrolled in the study between 1981 and 2006. Data from the Israeli Ministry of Interior was obtained by linkage. Follow-up terminated at the earliest of December 31st 2018 or death. Cox proportional hazard models were applied.

Results

There were 42,013 (67.6%) never smokers, 2,108 (3.4%) past smokers, 6,886 (11.1%) light, 9,880 (15.9%) medium and 1,247 (2%) heavy smokers. During 1,348,517 person-years, 548 deaths were recorded (327 were never smokers, and 18,54,121 and 28 were past, light, medium and heavy smokers, respectively; mean age 31.3 years). The hazard ratios for all-cause mortality were 0.98 (0.61–1.58), 1.02 (0.76–1.36), 1.32 (1.06–1.64) and 1.53 (1.03–2.30) for past smokers, light, medium and heavy smokers, respectively, after adjustment for age, gender, BMI, enrollment year, education and intelligence score. There was no sex-specific association and mortality risk among heavy smokers persisted even when the outcome was set as death by the age of 30 years.

Conclusion

Late-adolescent smoking is associated with long-term all-cause mortality. A dose-response relationship was demonstrated between number of cigarettes consumed at the age of 17 and the future risk of death.

Kaplan-Meier Plot

Funding Acknowledgement

Type of funding source: None
Visceral fat accumulation and left atrial phasic function in the general population
Authors: Sawada N , Nakanishi K , Daimon M , Yoshida Y , Ishiwata J , Hirokawa M , Koyama K , Nakao T , Morita H , Di Tullio M , Homma S , Komuro I
Published: November 2020

Background

Obesity carries independent risk for incident atrial fibrillation (AF), although the impact of abdominal fat distribution on LA morphological and functional remodeling is not fully elucidated. Speckle-tracking echocardiography is a novel and sensitive tool that allows quantification and detection of subtle alterations in left atrial (LA) phasic function.

Purpose

This study aimed to investigate whether increased visceral adiposity is independently associated with impaired LA phasic function in a community-based cohort.

Methods

We included 527 participants without overt cardiac disease who underwent laboratory testing, abdominal computed tomographic examination and speckle-tracking echocardiography. Abdominal adiposity was quantitatively assessed as visceral fat area (VFA) and subcutaneous fat area (SFA) at the level of the umbilicus. Speckle-tracking echocardiography was performed to assess LA phasic function including reservoir, conduit and pump strain as well as left ventricular global longitudinal strain (LVGLS).

Results

Mean age was 57±10 years and 362 of the participants (69%) were men. LA reservoir and conduit strain were decreased according to the VFA quartiles (both p<0.05), whereas there was no significant difference in LA volume index and LA pump strain. When stratified by SFA, there was no significant differences in LA volume index and all LA phasic strain across the quartiles. In multivariable analysis, VFA as continuous variable was significantly associated with LA conduit strain, independent of traditional cardiovascular risk factors, pertinent laboratory parameters and LV morphology and function including LVGLS (standardized b=−0.146, p=0.011). Representative cases are shown in the Figure.

Conclusion

In a sample of the general population, VFA accumulation was independently associated with worse LA conduit strain, which may be involved in the pathophysiological mechanism of obesity-related AF.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Yamauchi Susumu Scholarship for Cardiovascular Research
Percutaneous transcatheter bariatric embolotherapy for weight loss in obesity: two year data from a prospective RCT
Authors: Reddy V.Y , Fried M , Neuzil P , Rosen R , Sramkova P , Kipshidze N , Kipshidze N
Published: November 2020

Background/Introduction

Obesity is an important risk factor associated with poor cardiovascular and metabolic outcomes. Dietary, medical, and surgical weight loss strategies are often unsuccessful, unsustainable or accompanied by risks. Pre-clinical and early case series reported that transcatheter bariatric embolotherapy (TBE) of the left gastric artery reduces weight, by reducing “hunger” hormones from the gastric fundus. We studied TBE in a double-blind, sham procedure, first in human RCT of patients (pts) with obesity, and following completion of the initial study we asked subjects to return after 2 years post-embolization for further evaluation.

Purpose

The purpose of this extension study was to assess the long-term weight loss and other outcomes in subjects who underwent TBE for weight loss.

Methods

In the initial RCT subjects were randomized 1:1 to either a Sham (skin nick & 1 hr wait) or TBE following IV Propofol sedation. All pts received Lifestyle Therapy (behavioral and diet education); these staff following the pts were also blinded to treatment. Subjects completed the initial study when reaching the 1 year-follow-up visit. Subjects were then invited to return to the weight loss clinic at 2 years post-embolization for further evaluation on weight loss, blood pressure, pre-diabetic clinical status, satiety, and quality of life.

Results

A total of 44 pts (age 45.5±9.8; 36/8 M/F; BMI 39.6±3.8) were enrolled, of which 40 pts were randomized equally to groups, with no major complications. Mild, transient epigastric pain was seen, but EGDs showed no major abnormalities. Weight loss was improved with TBE by 6 mo, and maintained over the full 12 mo by both intention-to-treat and per-protocol analyses. At 2 years post-embolization, subjects treated with TBE demonstrated a mean 9% TBWL and 25% EBWL.

Conclusion(s)

Bariatric embolization is safe and when used along with lifestyle therapy, results in clinically significant weight loss. Long-term data demonstrates evidence that subjects treated with TBE continue to maintain their weight loss up to 2 years post-treatment.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Endobar Solutions LLC
Ten-year cardiovascular risk in diabetes patients without of coronary artery disease – a Danish cohort study
Authors: Olesen K.K.W , Madsen M , Gyldenkerne C , Thrane P.G , Thim T , Jensen L.O , Botker H.E , Sorensen H.T , Maeng M
Published: November 2020

Background

Patients with diabetes without obstructive coronary artery disease (CAD) by coronary angiography (CAG) have a risk of myocardial infarction (MI) similar to that of non-diabetes patients without CAD. Their cardiovascular risk compared to the general population is unknown.

Purpose

We examined the 10-year risks of myocardial infarction (MI), ischemic stroke, and death in diabetes patients without CAD after CAG compared to the general population.

Methods

We included all diabetes patients without obstructive CAD examined by CAG from 2003–2016 in Western Denmark and an age and sex matched comparison group, sampled from the general population in Western Denmark without previous history of coronary heart disease. Outcomes were MI, ischemic stroke, and death. The 10-year cumulative incidences were estimated. Adjusted hazard ratios (HRs) were estimated by stratified Cox regression using the general population as the reference group.

Results

We identified 5,760 diabetes patients without obstructive CAD and 29,139 individuals from the general population. Median follow-up was 7 years with 25% of participants followed for up to 10 years. Diabetes patients without obstructive CAD had an almost similar 10-year risk of MI (3.2% vs 2.9%, adjusted HR 0.91, 95% CI 0.70–1.17, Figure) compared to the general population cohort. Diabetes patients had an increased risk of ischemic stroke (5.2% vs 2.2%, adjusted HR 1.88, 95% CI 1.48–2.39), and death (29.7% vs 17.9%, adjusted HR 1.41, 95% CI 1.29–1.54). The duration of diabetes was associated with increased cardiovascular risk.

Conclusions

Absence of obstructive CAD by CAG in patients with diabetes ensures a low MI risk similar to the general population, but diabetes patients still have an increased risk of ischemic stroke and all-cause death despite absence of CAD.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital
Metabolic activity of visceral fat and immune-related organs evaluated by 18F-FDG PET/CT is associated with the metabolic syndrome
Authors: Pahk K , Kwon H.W , Eo J.S , Seo H.S , Kim S
Published: November 2020

Background

The risk of cardiovascular disease (CVD) is elevated in metabolic syndrome (MS) and is related to the inflammatory activity of visceral adipose tissue (VAT). We investigated whether the metabolic activity in VAT, assessed by 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT), is associated with systemic inflammatory status, and related to the number of MS components.

Methods

18F-FDG PET/CT was performed in a total of 203 subjects: 59 without an MS component; M(0), 92 with one or two MS components; M(1–2), and 52 with MS. Metabolic activity of VAT was evaluated using the mean standardized uptake value (SUVmean) and the maximum SUV (SUVmax). Metabolic activities of immune-related organs such as spleen and bone marrow (BM) were evaluated using the SUVmax.

Results

VAT SUVmax correlated with high-sensitivity C-reactive protein (hsCRP) and the SUVmax of spleen and BM, which reflect the status of systemic inflammation. Both hsCRP and the SUVmax of the spleen and BM were higher in the MS group than in the M(1–2) or M(0) groups. In VAT, SUVmax increased with increasing number of MS components, while SUVmean decreased.

Conclusions

The SUVmax of VAT assessed by 18F-FDG PET/CT could reflect the inflammatory activity of VAT which is increased in the MS patients with systemic inflammation.

Funding Acknowledgement

Type of funding source: None
Does high-normal 2-hour post load plasma glucose after myocardial infarction in patients with normal glucose tolerance adversely affect prognosis?
Authors: Chattopadhyay S , George A , John J , Sathyapalan T
Published: November 2020

Background

Type 2 diabetes mellitus (DM) and pre-DM, newly diagnosed after MI in patients without known DM adversely affects prognosis. 2-hour post-load glucose (2h-PG) predicts post-MI prognosis better than fasting plasma glucose (FPG). Plasma glucose below the conventional threshold for the diagnosis of impaired fasting glucose (IFG) and impaired glucose tolerance (IGT), affects post-MI prognosis.

Purpose

To test whether high-normal post-load plasma glucose in patients with normal glucose tolerance (NGT) would affect post-MI prognosis and whether FPG or 2h-PG increases this risk.

Methods

Retrospective cohort analysis of 425 MI survivors without known DM and with NGT followed up for (death and non-fatal MI) as MACE. MACE in patients with 2h-PG > median for the whole cohort (Group 2), was compared with those at or below (Group 1). Event free survival in the two groups was estimated from the Kaplan–Meier curves and compared using log-rank test. Cox proportional hazard regression identified predictors of MACE. Continuous net reclassification improvement (NRI>0) and integrated discrimination improvement (IDI) and c-statistics determined the added predictive value of glycaemic matrices.

Results

Median 2h-PG was 6.3 mmol/l. 219 patients in Group 1 and 206 in Group 2. Group 2 had higher age, prevalence of hypertension, hypercholesterolaemia, ST-segment depression and higher heart rate and GRACE scores. Median follow-up was 40.6 months. MACE was more frequent in Group 2 than Group 1 (OR 2.82, 95% CI 1.55 to 5.16, p<0.001). MACE-free survival was higher in Group 1 (HR 2.43, 95% CI 1.53 to 3.85, p<0.001). Group 2 (HR 2.42, 95% CI 1.44 to 4.04, p<0.001) predicted the MACE-free survival. 2h-PG, but not the FPG independently predicted of MACE (HR 1.73, 95% CI 1.31 to 2.30, p<0.001). Addition of 2h-PG to models containing FPG and other variables improved their predictive performance (NRI>0 0.5062, p<0.001; IDI 0.0376, p=0.003). The c-statistic increased when 2h-PG was added to the GRACE score only model (δAUC 0.037, 95% CI 0.012 to 0.081, p=0.046).

Conclusion(s)

This study suggests that “high-normal” 2h-PG is an independent predictor of post-MI prognosis. Normoglycaemic patients with 2h-PG ≥6.4 mmol/l, had worse post-MI prognosis compared to those with 2h-PG ≤6.3 mmol/l. The risk of MACE increased with increasing 2h-PG within the normal range. FPG had no effect on prognosis.

Funding Acknowledgement

Type of funding source: None
Efficacy of an mHealth intervention using interactive voice response system in reducing cardiovascular risk in a rural population in India: cluster randomized trial
Authors: Gupta R , Sharma A.K , Ahuja J , Baig V.N
Published: November 2020

Objective

We evaluated efficacy of mHealth technology for reducing cardiovascular risk among metabolic syndrome individuals in India.

Methods

We screened 1012 adults in 10 villages (clusters) in north-west India for presence of metabolic syndrome. Participants with inclusion criteria were randomized. Ownership of cell-phone was essential. We developed user-friendly interactive voice response system in Hindi based on transtheoretical model of behavior change. Two messages for promotion of healthy lifestyle and medical treatments were broadcast daily over 12-months in intervention clusters and queries answered. Lifestyle and biochemical factors were assessed at baseline and at 12-months.

Results

1012 rural individuals aged 20–60y in 10 villages were screened, majority were women (53%) and less literate (76%). Metabolic syndrome was in 286 (28.3%). These were divided into 5 control (n=136) and 5 intervention (n=147) clusters. Baseline characteristics in participants in control and intervention clusters were similar. At 12 months, significantly greater participants in intervention clusters had better lifestyle features and lower waist circumference, body mass index, systolic BP, fasting glucose, cholesterol and triglycerides (Table).

Conclusion

An interactive voice response system based technology significantly reduced multiple cardiovascular risk factors in metabolic syndrome individuals in rural India.

Funding Acknowledgement

Type of funding source: None
Effects of glucagon like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors and their combination on vascular function and myocardial work index in patient with type-2 diabetes
Authors: Ikonomidis I , Pavlidis G , Thymis J , Birba D , Kalogeris A , Kousathana F , Kountouri A , Balampanis K , Parissis J , Andreadou I , Katogiannis K , Dimitriadis G , Bamias A , Iliodromitis E , Lambadiari V
Published: November 2020

Background/Introduction

Type-2 diabetes mellitus (T2DM) is associated with endothelial and myocardial dysfunction.

Purpose

We investigated the effects of insulin, glucagon like peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and their combination on vascular and cardiac function of T2DM patients.

Methods

A hundred-sixty T2DM patients were randomized to insulin (n=40), liraglutide (n=40), empagliflozin (n=40) or their combination (GLP-1RA+SGLT-2i) (n=40) as add-on to metformin. We measured at baseline, 4 and 12 months post-treatment: a) perfused boundary region (PBR) of the sublingual arterial microvessels (marker of glycocalyx thickness), b) pulse wave velocity (PWV), central systolic blood pressure (cSBP), c) global LV longitudinal (GLS), circumferential (GCS) and radial (GRS) strain, d) the ratio PWV/GLS, as an index of ventricular-arterial interaction, e) myocardial work index (GWI) using speckle tracking imaging.

Results

Twelve months post-treatment, all patients improved PBR, PWV, GLS, GCS and GRS (p<0.05). GLP-1RA, SGLT-2i and their combination showed a greater reduction of PBR, PWV and cSBP than insulin, despite a similar HbA1c reduction (p<0.05). GLP-1RA or GLP-1RA+SGLT-2i provided a greater decrease of PWV/GLS (28.1% and 31% vs. 11.1% and 14.5%) and a greater increase of GWI (12.7% and 17.4% vs. 3.1% and 2%) compared with insulin or SGLT-2i. SGLT-2i or GLP-1RA+SGLT-2i showed a greater decrease of PWV (10.1% and 13%), cSBP than insulin or GLP-1RA (PWV: 3.6% and 8.6%) (p<0.05 for all comparisons) (Table 1). The dual therapy showed the greatest effect on measured markers in patients with LVEF <55% (p<0.05).

Conclusions

Twelve-month treatment with GLP-1RA, SGLT-2i and their combination showed a greater improvement of vascular markers and effective cardiac work than insulin in T2DM. The combined therapy was superior to either insulin, or GLP-1RA and SGLT-2i separately.

Funding Acknowledgement

Type of funding source: None
Impact of timing of randomization after an acute coronary syndrome and subsequent events in patients with type 2 diabetes mellitus: an analysis of the EXAMINE trial
Authors: Elharram M , Sharma A , White W , Bakris G , Rossignol P , Mehta C , Ferreira J , Zannad F
Published: November 2020

Background

The timing of enrolment following an acute coronary syndrome (ACS) may influence cardiovascular (CV) outcomes and potentially treatment effect in clinical trials. Using a large contemporary trial in patients with type 2 diabetes mellitus (T2DM) post-ACS, we examined the impact of timing of enrolment on subsequent CV outcomes.

Methods

EXAMINE was a randomized trial of alogliptin versus placebo in 5380 patients with T2DM and a recent ACS. The primary outcome was a composite of CV death, non-fatal myocardial infarction [MI], or non-fatal stroke. The median follow-up was 18 months. In this post hoc analysis, we examined the occurrence of subsequent CV events by timing of enrollment divided by tertiles of time from ACS to randomization: 8–34, 35–56, and 57–141 days.

Results

Patients randomized early (compared to the latest times) had less comorbidities at baseline including a history of heart failure (HF; 24.7% vs. 33.0%), prior coronary artery bypass graft (9.6% vs. 15.9%), or atrial fibrillation (5.9% vs. 9.4%). Despite the reduced comorbidity burden, the risk of the primary outcome was highest in patients randomized early compared to the latest time (adjusted hazard ratio [aHR] 1.47; 95% CI 1.21–1.74) (Figure 1). Similarly, patients randomized early had an increased risk of recurrent MI (aHR 1.51; 95% CI 1.17–1.96) and HF hospitalization (1.49; 95% CI 1.05–2.10).

Conclusion

In a contemporary cohort of T2DM with a recent ACS, early randomization following the ACS increases the risk of CV events including recurrent MI and HF hospitalization. This should be taken into account when designing future clinical trials.

Figure 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Takeda Pharmaceutical
Association of baseline hemoglobin A1c levels with bleeding in patients with non-ST-segment elevation acute coronary syndrome underwent percutaneous coronary intervention
Authors: Fan H.L , Liu Y.H , Chen P.Y , Jiang L , Wei X.B , Guo W , Zeng L.H , Tan N , Chen J.Y , He P.C
Published: November 2020

Background

The association between baseline hemoglobin A1c (HbA1c) levels before the percutaneous coronary intervention and bleeding is unclear in patients with non-ST-segment elevation acute coronary syndrome.

Purpose

To investigate the association between baseline HbA1c levels before the percutaneous coronary intervention and bleeding in patients with non-ST-segment elevation acute coronary syndrome.

Methods

This observational cohort study enrolled 6,283 consecutive patients with non-ST-segment elevation acute coronary syndrome, from 1 January 2010 to 31 December 2014. Based on baseline HbA1c levels, the patients were divided into the HbA1c <7% group (n=4,740) and the HbA1c ≥7% group (n=1,543). The primary outcomes are major bleeding events (BARC grades 3–5) and all-cause death during follow-up.

Results

Of the patients who were enrolled, 4,705 (74.9%) were male and 2,143 (34.1%) had a history of diabetes mellitus, with a mean (SD) age of 64.13 (10.32) years. Median follow-up duration was 3.21 years. Compared with HbA1c <7% patients, the risk of major bleeding events and all-cause was both higher in HbA1c ≥7% patients (major bleeding: adjusted hazard ratio, 1.62; 95% confidence interval, 1.04–2.53; P=0.032; all-cause death: adjusted hazard ratio, 1.26; 95% confidence interval, 1.03–1.55; P=0.027). The result of the subgroups analyses was consistent with the primary analyses.

Conclusions

Higher baseline HbA1c levels before percutaneous coronary intervention was associated with an increase in bleeding risk in non-ST-elevation acute coronary syndrome patients. This study suggests that the HbA1c levels should be taken into account for the prolonged antithrombotic strategies of non-ST-elevation acute coronary syndrome patients.

Figure 1. Kaplan-Meier Analysis for Outcomes

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Science and Technology Planning Project of Guangzhou City (201707010002)