Circulating ketone bodies and cardiovascular outcomes: the MESA study.

AIMS: Ketone bodies (KB) are an important alternative metabolic fuel source for the myocardium. Experimental and human investigations suggest that KB may have protective effects in patients with heart failure. This study aimed to examine the association between KB and cardiovascular outcomes and mortality in an ethnically diverse population free from cardiovascular disease (CVD). METHODS AND RESULTS: This analysis included 6796 participants (mean age 62 ± 10 years, 53% women) from the Multi-Ethnic Study of Atherosclerosis. Total KB was measured by nuclear magnetic resonance spectroscopy. Multivariable-adjusted Cox proportional hazard models were used to examine the association of total KB with cardiovascular outcomes. At a mean follow-up of 13.6 years, after adjusting for traditional CVD risk factors, increasing total KB was associated with a higher rate of hard CVD, defined as a composite of myocardial infarction, resuscitated cardiac arrest, stroke, and cardiovascular death, and all CVD (additionally included adjudicated angina) [hazard ratio, HR (95% confidence interval, CI): 1.54 (1.12-2.12) and 1.37 (1.04-1.80) per 10-fold increase in total KB, respectively]. Participants also experienced an 87% (95% CI: 1.17-2.97) increased rate of CVD mortality and an 81% (1.45-2.23) increased rate of all-cause mortality per 10-fold increase in total KB. Moreover, a higher rate of incident heart failure was observed with increasing total KB [1.68 (1.07-2.65), per 10-fold increase in total KB]. CONCLUSION: The study found that elevated endogenous KB in a healthy community-based population is associated with a higher rate of CVD and mortality. Ketone bodies could serve as a potential biomarker for cardiovascular risk assessment.

Understanding the molecular mechanisms of statin pleiotropic effects.

Statins represent the cornerstone of pharmacotherapy for the prevention of atherosclerotic cardiovascular disease. These medications not only reduce low-density lipoprotein cholesterol (LDL-C) via inhibition of 3-hydroxy-3-methylglutarate attached to CoA reductase, the key rate-limiting step in the cholesterol biosynthetic pathway, but also upregulate expression of the low-density lipoprotein receptor, improving serum clearance. Given LDL-C is a causal risk factor for the development of atherosclerosis, these complementary mechanisms largely explain why statin therapy leads to reductions in major adverse cardiovascular events. However, decades of basic and clinical research have suggested that statins may exert other effects independent of LDL-C lowering, termed pleiotropic effects, which have become a topic of debate among the scientific community. While some literature suggests statins may improve plaque stability, reduce inflammation and thrombosis, decrease oxidative stress, and improve endothelial function and vascular tone, other studies have suggested potential harmful pleiotropic effects related to increased risk of muscle-related side effects, diabetes, hemorrhagic stroke, and cognitive decline. Furthermore, the introduction of newer, non-statin LDL-C lowering therapies, including ezetimibe, proprotein convertase subtilisin/Kexin Type 9, and bempedoic acid, have challenged the statin pleiotropy theory. This review aims to provide a historical background on the development of statins, explore the mechanistic underpinnings of statin pleiotropy, review the available literature, and provide up to date examples that suggest statins may exert effects outside of LDL-C lowering and the cardiovascular system.

Association of silent myocardial infarction on electrocardiogram and coronary artery calcium: The Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: Silent myocardial infarction (SMI) on electrocardiogram (ECG) is associated with atherosclerotic cardiovascular disease, but the relationship between SMI on ECG and coronary artery calcium (CAC) remains poorly understood. OBJECTIVE: Characterize the relationship between SMI on ECG and CAC. METHODS: Eligible participants from the Multi-Ethnic Study of Atherosclerosis study had ECG and CAC scoring at study enrollment (2000-2002). SMI was defined as ECG evidence of myocardial infarction in the absence of a history of clinical cardiovascular disease. CAC was modeled both continuously and categorically. The cross-sectional relationships between SMI on ECG and CAC were assessed using logistic regression and linear regression. RESULTS: Among 6705 eligible participants, 178 (2.7%) had baseline SMI. Compared to participants without SMI, those with SMI had higher CAC (median [IQR]: 61.2 [0-261.7] vs. 0 [0-81.5]; p < .0001). Participants with SMI were more likely to have non-zero CAC (74% vs. 49%) and were more likely to have CAC ≥ 100 (40% vs. 23%). In a multivariable-adjusted logistic model, SMI was associated with higher odds of non-zero CAC (odds ratio 2.17, 95% CI 1.48-3.20, p < .0001) and 51% higher odds of CAC ≥ 100 (odds ratio 1.51, 95% CI 1.06-2.16, p = .02). CONCLUSION: An incidental finding of SMI on ECG may serve to identify patients who have a higher odds of significant CAC and may benefit from additional risk stratification to further refine their cardiovascular risk. Further exploration of the utility of CAC assessment in this patient population is needed.

Specialty preference for cardiovascular prevention practice in the Southeast US and role of a preventive cardiologist.

INTRODUCTION: Cardiovascular disease (CVD) prevention is practiced concurrently by providers from several specialties. Our goal was to understand providers' preference of specialties in CVD prevention practice and the role of preventive cardiologists. MATERIALS AND METHODS: Between 11 October 2021 and 1 March 2022, we surveyed providers from internal medicine, family medicine, endocrinology, and cardiology specialties to examine their preference of specialties in managing various domains of CVD prevention. We examined categorical variables using Chi square test and continuous variables using t or analysis of variance test. RESULTS: Of 956 invitees, 263 from 21 health systems and 9 states responded. Majority of respondents were women (54.5%), practicing physicians (72.5%), specializing in cardiology (43.6%), and working at academic centers (51.3%). Respondents favored all specialties to prescribe statins (43.2%), ezetimibe (37.8%), sodium-glucose cotransporter-2 (SGLT2) inhibitors (30.5%), and aspirin in primary prevention (36.3%). Only 7.9% and 9.5% selected cardiologists and preventive cardiologists, respectively, to prescribe SGLT2 inhibitors. Most preferred specialists (i.e. cardiology and endocrinology) to manage advanced lipid disorders, refractory hypertension, and premature coronary heart disease. The most common conditions selected for preventive cardiologists to manage were genetic lipid disorders (17%), cardiovascular risk assessment (15%), dyslipidemia (13%), and refractory/resistant hypertension (12%). CONCLUSIONS: For CVD prevention practice, providers favored all specialties to manage common conditions, specialists to manage complex conditions, and preventive cardiologists to manage advanced lipid disorders. Cardiologists were least preferred to prescribe SGLT2 inhibitor. Future research should explore reasons for selected CVD prevention practice preferences to optimize care coordination and for effective use of limited expertise.

Should a Statin be Given to All Hypertensive Patients?

PURPOSE OF REVIEW: To review the milestone trials and recent literature supporting statin therapy for prevention of atherosclerotic cardiovascular disease (ASCVD) and to provide rationale for more generalized use of statin therapy among patients treated for hypertension. RECENT FINDINGS: Hypertension is a leading modifiable risk factor for ASCVD worldwide. Randomized controlled trial evidence supports initiation of antihypertensive medication for stage 2 hypertension regardless of ASCVD risk. The HOPE-3 trial tested statin therapy in intermediate-risk individuals (defined as an annual risk of major cardiovascular events of approximately 1%) for primary prevention of ASCVD and reported significant reductions in cardiovascular events in all statin treatment arms, with the greatest benefit observed in patients in the highest tertile of systolic blood pressure. Based on the current data, patients with stage 2 hypertension with an indication for antihypertensive therapy may benefit from the addition of statin therapy in the primary prevention setting. Patients with hypertension have an elevated risk for ASCVD that appears to be modifiable beyond implementation of antihypertensive therapy. The addition of statin therapy in patients treated with antihypertensive therapy may further help to lower risk of future cardiovascular events.

Polygenic Risk Scores to Identify CVD Risk and Tailor Therapy: Hope or Hype?

PURPOSE OF REVIEW: The purpose of this review is to understand the conceptual basis and implications of polygenic risk scores (PRS) in assessing risk of future coronary artery disease (CAD). RECENT FINDINGS: Genetic information from the USA and beyond has been pooled together to create population-based biobanks, composed of millions of genotyped individuals, which have helped further our understanding of the relationship between single nucleotide polymorphisms (SNPs) and CAD. Contemporary PRS composed of millions of SNPs now serve as the gold standard and have been evaluated in several cohort studies to predict risk of CAD and potentially help guide pharmacotherapy. The development of PRS has enhanced our understanding of the relationship between genes and disease, thereby facilitating CAD risk prediction. While certain constraints currently limit their utility in clinical practice, further refinement of this tool will enable clinicians to more fully understand genetic risk and improve preventive care.

The utility of silent myocardial infarction on electrocardiogram as an ASCVD risk enhancer for primary prevention: The multi-ethnic study of atherosclerosis.

BACKGROUND: The 2018 AHA/ACC cholesterol guidelines introduced a new list of markers called "risk enhancers" that, if present, confer an increased risk of atherosclerotic cardiovascular disease (ASCVD). Silent myocardial infarction (SMI) on electrocardiogram (ECG) is notably absent, even though it associated with future ASCVD. METHODS: We assessed the utility of SMI on ECG as a risk-enhancer in intermediate-risk participants in MESA (Multi-Ethnic Study of Atherosclerosis) - those with 10-year ASCVD risk of 5-20% by the pooled cohort equation (PCE). SMI was defined as major Q-wave abnormality or minor Q/QS waves in the setting of major ST-T abnormalities without prevalent clinical cardiovascular disease. RESULTS: Among 2946 participants (mean age 63.1 ± 7.6, 53.9% women, 36% white, 11% Chinese-American, 33% African-American, 19% Hispanic), 66 (2.2%) had SMI at baseline. After a median 15.8 years of follow-up, incident ASCVD events occurred in 431/2876 (15.0%) of those without SMI and 16/66 (24.2%) of those with SMI. In a multivariable-adjusted Cox proportional hazards model, baseline SMI was associated with an increased risk of incident ASCVD events (HR 1.68, 95% CI 1.02-2.77, p = 0.04). However, adding SMI to the PCE did not improve discrimination and reclassification was modest-net reclassification improvement was 0.0161 (95% CI 0.002-0.034, p = 0.08). CONCLUSION: Our findings suggest that the prevalence of SMI is 2.2% among those without known clinical cardiovascular disease considered intermediate-risk by the PCE. In our analysis, SMI only modestly improved classification of risk, suggesting that it may not be very useful as an ASCVD risk enhancer.

Obstructive coronary artery disease with a coronary artery calcium score of 0: A case report.

Coronary artery calcium (CAC) scoring has emerged as a useful tool in identifying patients who may benefit from more aggressive risk factor modification and for prognostication. Although a CAC score of 0 is associated with a very low prevalence of obstructive epicardial coronary artery disease and low event rates, it can also provide a false sense of reassurance. We present a case of a 39-year-old woman with a CAC score of 0 obtained as part of a coronary computerized tomography angiography study that was ultimately found to have significant left anterior descending artery disease requiring percutaneous coronary intervention and a stent.

QRS duration is associated with all-cause mortality in type 2 diabetes: The diabetes heart study.

BACKGROUND: QRS-duration predicts mortality in patients with heart failure and, to a lesser extent, the general population. However, in patients with diabetes, its prognostic significance is unknown. To better understand how QRS-duration relates to mortality among those with diabetes, we explored survival as a function of QRS-duration in the Diabetes Heart Study. METHODS: The study population included 1335 participants. Cox proportional hazards modeling was used to evaluate the relationship between QRS-duration and all-cause mortality, comparing those with QRS-duration ≤120 vs. >120 (ms). Multivariable models adjusted for age, sex, race, hypertension, smoking, years with diabetes, BMI, systolic blood pressure, cholesterol, triglycerides, glomerular filtration rate, and hemoglobin A1c. RESULTS AND CONCLUSIONS: Participants were: mean age 61 ± 9, 55% women, 83% white; 99 participants (7.5%) had a QRS-duration >120. After 11,000 person-years of follow-up (median 8.5 years; maximum 13.9 years), 266 participants had died (20%). Participants with baseline QRS-duration >120 had an adjusted hazard ratio for all-cause mortality of 1.56 (95% CI 1.05-2.24; p = 0.027). Modeling QRS-duration as a continuous variable, we found an 11% increase in all-cause mortality for each 10 ms increase in QRS-duration. In conclusion, QRS-duration is associated with subsequent all-cause mortality among those with type 2 diabetes-participants with QRS-duration >120 ms had a 56% increase in all-cause mortality, even after adjustment for conventional risk factors. Given the ubiquitous presence of ECG data in the medical record, QRS-duration may prove to be a useful prognostic measure, especially among those with diabetes.

Management of Patients With Chronic Coronary Disease.

This JAMA Clinical Guidelines Synopsis summarizes the 2023 American Heart Association (AHA)/American College of Cardiology (ACC) guideline on management of patients with chronic coronary disease.

Simulation-based training in echocardiography.

The knowledge gained from echocardiography is paramount for the clinician in diagnosing, interpreting, and treating various forms of disease. While cardiologists traditionally have undergone training in this imaging modality during their fellowship, many other specialties are beginning to show interest as well, including intensive care, anesthesia, and primary care trainees, in both transesophageal and transthoracic echocardiography. Advances in technology have led to the development of simulation programs accessible to trainees to help gain proficiency in the nuances of obtaining quality images, in a low stress, pressure free environment, often with a functioning ultrasound probe and mannequin that can mimic many of the pathologies seen in living patients. Although there are various training simulation programs each with their own benefits and drawbacks, it is clear that these programs are a powerful tool in educating the trainee and likely will lead to improved patient outcomes.

How to interpret a cardiorespiratory fitness assessment - Key measures that provide the best picture of health, disease status and prognosis.

Graded exercise testing is a widely accepted tool for revealing cardiac ischemia and/or arrhythmias in clinical settings. Cardiopulmonary exercise testing (CPET) measures expired gases during a graded exercise test making it a versatile tool that helps reveal underlying physiologic abnormalities that are in many cases only present with exertion. It also characterizes one's health status and clinical trajectory, informs the therapeutic plan, evaluates the efficacy of therapy, and provides submaximal and maximal information that can be used to tailor an exercise intervention. Practitioners can also modify the mode and protocol to allow individuals of all ages, fitness levels, and most disease states to perform a CPET. When used to its full potential, CPET can be a key tool used to optimize care in primary and secondary prevention settings.

Enhancing the Cardiovascular Health Construct With a Psychological Health Metric for Predicting Mortality Risk.

Background: The American Heart Association's Life's Essential 8 (LE8) Presidential Advisory deemed psychological health foundational for cardiovascular health (CVH) but did not include it as a CVH metric. Objectives: The purpose of this study was to evaluate associations of a CVH construct enhanced with a ninth metric for psychological health based on readily administered depression screening with mortality risk in U.S. adults. Methods: Participants were 21,183 adults (mean age: 48y, 51% female, 11% Black, 15% Hispanic, 65% White) from the 2011 to 2018 National Health and Nutrition Examination Survey. The LE8 algorithm was used to assess CVH. Two enhanced CVH constructs that include a ninth psychological health metric based on depression screening using the Patient Health Questionnaires (PHQ-2 and PHQ-9) were computed. Multivariable Cox proportional hazards models compared all-cause and cause-specific mortality risk across CVH score tertiles and a priori defined categories (high: 80-100, moderate: 50-79, low: 0-49) in the overall sample and by sex and race and ethnicity. Results: There were 1,397 deaths (414 cardiovascular and 329 cancer deaths). High vs low CVH scores, enhanced with PHQ-2 and PHQ-9, were associated with 69% and 70% lower mortality risk, while a high vs low LE8 score was associated with 65% lower risk (p-trend<0.001). Higher LE8 and enhanced CVH scores predicted lower mortality risk in both sexes and in Black and White but not Hispanic adults and were also associated with lower cardiovascular and cancer mortality. Both enhanced CVH scores had excellent performance for predicting mortality, similar to the LE8 score (C-statistic = 0.843 vs 0.842, P < 0.001). Conclusions: A CVH construct enhanced with psychological health strongly predicts mortality. Inclusion of psychological health as a ninth CVH metric, with depression screening as a feasible proxy in clinical and public health settings, should be considered.

2023 update: The importance of cardiorespiratory fitness in the United States.

The American Heart Association issued a Policy Statement in 2013 that characterized the importance of cardiorespiratory fitness (CRF) as an essential marker of health outcomes and specifically the need for increased assessment of CRF. This statement summarized the evidence demonstrating that CRF is "one of the most important correlates of overall health status and a potent predictor of an individual's future risk of cardiovascular disease." Subsequently, this Policy Statement led to the development of a National Registry for CRF (Fitness Registry and the Importance of Exercise: A National Data Base [FRIEND]) which established normative reference values for CRF for adults in the United States (US). This review provides an overview of the progress made in the past decade to further our understanding of the importance of CRF, specifically related to prevention and for clinical populations. Additionally, this review overviews the evolvement and additional uses of FRIEND and summarizes a hierarchy of assessment methods for CRF. In summary, continued efforts are needed to expand the representation of data from across the US, and to include data from pediatric populations, to further develop the CRF Reference Standards for the US as well as further develop Global CRF Reference Standards.

Rest-Activity Rhythms Are Associated With Prevalent Cardiovascular Disease, Hypertension, Obesity, and Central Adiposity in a Nationally Representative Sample of US Adults.

BACKGROUND: Rest-activity rhythms (RARs), a measure of circadian rhythmicity in the free-living setting, are related to mortality risk, but evidence is limited on associations with cardiovascular disease (CVD) and its risk factors. METHODS AND RESULTS: Participants included 4521 adults from the 2013 to 2014 National Health and Nutrition Examination Survey physical activity monitoring examination. Wrist-worn ActiGraph GT3X+ data were used to estimate RARs. Multivariable logistic models evaluated associations of RARs with prevalent CVD, hypertension, obesity, and central adiposity. Participants (mean age, 49 years) in the highest versus lowest tertile of relative amplitude (greater circadian rhythmicity) had 39% to 62% lower odds of prevalent CVD, hypertension, obesity, and central adiposity. A more active wake period was associated with 19% to 72% lower CVD, hypertension, obesity, and central adiposity odds. Higher interdaily stability (regular sleep-wake and rest-activity patterns) was related to 52% and 23% lower CVD and obesity odds, respectively. In contrast, participants in the highest versus lowest tertile of intradaily variability (fragmented RAR and inefficient sleep) had >3-fold and 24% higher CVD and obesity odds, respectively. A later and less restful sleep period was associated with 36% to 2-fold higher CVD, hypertension, obesity, and central adiposity odds. A statistically significant linear trend was observed for all associations (P-trend<0.05). CONCLUSIONS: A robust, stable, and less fragmented RAR, an active wake period, and an earlier and more restful sleep period are associated with lower prevalent CVD, hypertension, obesity, and central adiposity, with evidence of a dose-response relationship. The magnitude, timing, and regularity of sleep-wake and rest-activity patterns may be important targets for reducing cardiovascular risk.

Small dense low-density lipoprotein cholesterol and coronary artery calcification in the Multi-Ethnic Study of Atherosclerosis.

AIMS: Elevated small dense LDL cholesterol (sd-LDL-C) increases atherosclerotic cardiovascular disease (CVD) risk. Although coronary artery calcification (CAC) is widely used for predicting CVD events, few studies have examined the relationship between sd-LDL-C and CAC. METHODS AND RESULTS: This study included 4672 individuals with directly measured baseline sd-LDL-C and CAC from the Multi-Ethnic Study of Atherosclerosis [mean (standard deviation) age: 61.9 (10.4) years; 52.5% women; 47.3% with baseline CAC (mean score >0)]. We used multi-variable general linear models and restricted cubic splines with the goodness of fit testing to evaluate the association of sd-LDL-C with the presence of CAC. Odds ratios [OR (95% confidence interval)] were adjusted for demographics and cardiovascular risk factors, including estimated total LDL-C. Higher quartiles of sd-LDL-C were associated with the presence of CAC, even after accounting for total LDL-C. Compared with the lowest quartile of sd-LDL-C, participants in Quartiles 2, 3, and 4 had higher odds for the presence of baseline CAC [Quartile 2 OR: 1.24 (1.00, 1.53); Quartile 3 OR: 1.51 (1.19, 1.93); and Quartile 4 OR 1.59 (1.17, 2.16)]. Splines suggested a quadratic curvilinear relationship of continuous sd-LDL-C with CAC after adjustment for demographics and CVD risk factors (quadratic vs. first-order sd-LDL-C terms likelihood ratio test: P = 0.015), but not after accounting for total LDL-C (quadratic vs. first-order terms: P = 0.156). CONCLUSION: In a large, multi-ethnic sample without known CVD, higher sd-LDL-C was associated with the presence of CAC, above and beyond total LDL-C. Whether selective direct measurement of sd-LDL-C is indicated to refine cardiovascular risk assessment in primary prevention warrants further investigation.

Higher levels of small dense particles of LDL cholesterol, better known as the 'bad cholesterol', are associated with a greater risk for the presence of coronary artery calcium, a strong marker for heart disease, even when accounting for estimated total (small dense + large body particles) LDL cholesterol.This risk is stronger in older individuals.Peak risk seems to occur between 49 and 71 mg/dL and does not increase further at higher levels.

Self-rated health and risk of incident cardiovascular events among individuals with hypertension.

BACKGROUND: The relationship between self-rated health (SRH) and cardiovascular events in individuals with hypertension, but without diabetes mellitus, is understudied. METHODS: We performed a post hoc analysis of data from SPRINT (Systolic Blood Pressure Intervention Trial). SRH was categorized into excellent, very good, good and fair/poor. Using multivariable Cox regression, we estimated hazard ratios and 95% confidence intervals (CIs) for the association of SRH with both all-cause mortality and a composite of cardiovascular events (the primary outcome), which was defined to include myocardial infarction (MI), other acute coronary syndromes, stroke, acute decompensated heart failure, and cardiovascular death. RESULTS: We included 9319 SPRINT participants (aged 67.9 ±â€Š9 years, 35.6% women) with a median follow-up of 3.8 years. Compared with SRH of excellent, the risk [hazard ratio (95% CI)] of the primary outcome associated with very good, good, and fair/poor SRH was 1.11(0.78-1.56), 1.45 (1.03-2.05), and 1.87(1.28-2.75), respectively. Similarly, compared with SRH of excellent, the risk of all-cause mortality [hazard ratio (95% CI)] associated with very good, good, and fair/poor SRH was 1.13 (0.73-1.76), 1.72 (1.12-2.64), and 2.11 (1.32-3.38), respectively. Less favorable SRH (LF-SRH) was also associated with a higher risk of each component of the primary outcome and serious adverse events (SAE). CONCLUSION: Among individuals with hypertension, SRH is independently associated with the risk of incident cardiovascular events, all-cause mortality, and SAE. Our study suggest that guidelines should consider the potential significance of including SRH in the clinical history of patients with hypertension.

High density lipoprotein: When to rethink too much of a good thing.

High density lipoprotein cholesterol (HDL-C) is a known contributor to atherosclerotic cardiovascular disease (ASCVD) risk when HDL-C <40 mg/dL in men and <50 mg/dL in women. There has been much interest in the potential cardioprotective properties of HDL-C, as it removes cholesterol from the periphery to the liver for exertion and holds inherent anti-thrombotic and anti-inflammatory properties. However, clinical trials raising HDL-C pharmacologically have not shown to improve cardiovascular outcomes. In fact, observational studies have demonstrated an increased risk of non-cardiovascular mortality and infection when HDL-C >90 mg/dL and >70 mg/dL in women and men, respectively. The ability for the HDL particle to effectively transport cholesterol from the periphery for excretion in bile is more complex than illustrated on a standard cholesterol panel. There is variability in its function, size, density, subclass, reverse cholesterol transport, and cholesterol efflux capacity, which impact the particles ability to effectively reduce cardiovascular disease (CVD) risk. Research has shown that HDL particles are prone to have a reduction in its efficacy in response to infection, auto-immune disease, menopause and cardiometabolic conditions during pregnancy. Additionally, recent studies have shown that low HDL-C may not adequately influence ASCVD risk in Black adults. The purpose of this contemporary review is to highlight the utility of using HDL-C in assessing CVD risk.

Obesity management for cardiovascular disease prevention.

Background: Obesity is a complex disease that leads to higher morbidity and mortality and its rate in the United States is rapidly rising. Targeting obesity management is one of the cornerstones of preventive medicine. Early intervention can significantly reduce the risk of developing cardiovascular disease. While it is well known that lifestyle interventions such as healthful nutrition and routine physical activity are the first and most important step in management, some do not achieve the desired results and require further therapies. Methods: A literature review was conducted, that included clinical documents, public scientific citations and peer review articles to evaluate anti-obesity medications, endoscopic procedures and bariatric surgeries in the management of obesity. We also included effects of these interventions on weight loss, cardiovascular disease risk reduction and side effects. Results: This clinical review summarizes recent evidence for the different approaches in obesity management including medications, common endoscopic procedures and bariatric surgeries. For more detailed review on the different management options discussed, we recommend reviewing Obesity Medicine Association Clinical Practice Statement [1]. Conclusion: Management of obesity reduces cardiovascular risk, improves metabolic parameters and other important health outcomes. Different management approaches are available, hence, a high level of awareness of the growing epidemic of obesity is needed to ensure timely referrals to obesity medicine specialists.

What has cardiac rehabilitation looked like in the COVID-19 pandemic: Lessons learned for the future.

The global coronavirus disease 2019 (COVID-19) pandemic prompted widespread national shutdown, halting or dramatically reducing the delivery of non-essential outpatient services including cardiac rehabilitation (CR). Center-based CR services were closed for as few as two weeks to greater than one year and the uncertainty surrounding the duration of the lockdown phase prompted programs to consider programmatic adaptations that would allow for the safe and effective delivery of CR services. Among the actions taken to accommodate in person CR sessions included increasing the distance between exercise equipment and/or limiting the number of patients per session. Legislative approval of reimbursing telehealth or virtual services presented an opportunity to reach patients that may otherwise have not considered attending CR during or even before the pandemic. Additionally, the considerable range of symptoms and infection severity as well as the risk of developing long lasting, debilitating symptoms has complicated exercise recommendations. Important lessons from publications reporting findings from clinical settings have helped shape the way in which exercise is applied, with much more left to discover. The overarching aim of this paper is to review how programs adapted to the COVID-19 pandemic and identify lessons learned that have positively influenced the future of CR delivery.