Medical and Surgical Obesity Treatments and Atherosclerosis: Mechanisms beyond Typical Risk Factors.

PURPOSE OF REVIEW: This study aims to discuss the mechanisms by which GLP-1 agonists and bariatric surgery improve cardiovascular outcomes in severely obese patients. RECENT FINDINGS: Recent studies have demonstrated that both GLP-1 agonist use and bariatric surgery reduce adverse cardiovascular outcomes. Improvements in traditional atherosclerosis risk factors in association with weight loss likely contribute, but weight loss-independent mechanisms are also suggested to have roles. We review the clinical and preclinical evidence base for cardiovascular benefit of LP-1 agonists and bariatric surgery beyond traditional risk factors, including improvements in endothelial function, direct impacts on atherosclerotic plaques, and anti-inflammatory effects.

Ten things to know about ten cardiovascular disease risk factors.

Given rapid advancements in medical science, it is often challenging for the busy clinician to remain up-to-date on the fundamental and multifaceted aspects of preventive cardiology and maintain awareness of the latest guidelines applicable to cardiovascular disease (CVD) risk factors. The "American Society for Preventive Cardiology (ASPC) Top Ten CVD Risk Factors 2021 Update" is a summary document (updated yearly) regarding CVD risk factors. This "ASPC Top Ten CVD Risk Factors 2021 Update" summary document reflects the perspective of the section authors regarding ten things to know about ten sentinel CVD risk factors. It also includes quick access to sentinel references (applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful nutrition, physical inactivity, dyslipidemia, hyperglycemia, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis/smoking, kidney dysfunction and genetics/familial hypercholesterolemia. For the individual patient, other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the "ASPC Top Ten CVD Risk Factors 2021 Update" to provide a succinct overview of things to know about ten common CVD risk factors applicable to preventive cardiology.

Early Termination of Cardiac Rehabilitation Is More Common With Heart Failure With Reduced Ejection Fraction Than With Ischemic Heart Disease.

PURPOSE: Despite known benefits of cardiac rehabilitation (CR), early termination (failure to complete >1 mo of CR) attenuates these benefits. We analyzed whether early termination varied by referral indication in the context of recent growth in patients referred for heart failure with reduced ejection fraction (HFrEF). METHODS: We reviewed records from 1111 consecutive patients enrolled in the NYU Langone Health Rusk CR program (2013-2017). Sessions attended, demographics, and comorbidities were abstracted, as well as primary referral indication: HFrEF or ischemic heart disease (IHD; including post-coronary revascularization, post-acute myocardial infarction, or chronic stable angina). We compared rates of early termination between HFrEF and IHD, and used multivariable logistic regression to determine whether differences persisted after adjusting for relevant characteristics (age, race, ethnicity, body mass index, smoking, hypertension, chronic obstructive pulmonary disease, and depression). RESULTS: Mean patient age was 64 yr, 31% were female, and 28% were nonwhite. Most referrals (85%) were for IHD; 15% were for HFrEF. Early termination occurred in 206 patients (18%) and was more common in HFrEF (26%) than in IHD (17%) (P < .01). After multivariable adjustment, patients with HFrEF remained at higher risk of early termination than patients with IHD (unadjusted OR = 1.73, 95% CI, 1.17-2.54; adjusted OR = 1.53, 95% CI, 1.01-2.31). CONCLUSIONS: Nearly 1 in 5 patients in our program terminated CR within 1 mo, with HFrEF patients at higher risk than IHD patients. While broad efforts at preventing early termination are warranted, particular attention may be required in patients with HFrEF.

Study protocol for Smartphone Monitoring for Atrial fibrillation in Real-Time in India (SMART-India): a community-based screening and referral programme.

INTRODUCTION: Atrial fibrillation (AF), the world's most common arrhythmia, often goes undetected and untreated in low-resource communities, including India, where AF epidemiology is undefined. AF is an important risk factor for stroke, which plagues an estimated 1.6 million Indians annually. As such, early detection of AF and management of high-risk patients is critically important to decrease stroke burden in individuals with AF. This study aims to describe the epidemiology of AF in Anand District, Gujarat, India, characterise the clinical profile of individuals who are diagnosed with AF and determine the performance of two mobile technologies for community-based AF screening. METHODS: This observational study builds on findings from a previous feasibility study and leverages two novel technologies as well as an existing community health programme to perform door-to-door AF screening for 2000 people from 60 villages of Anand District, Gujarat, India using local health workers. A single-lead ECG and a pulse-based application is used to screen each individual for AF three times over a period of 5 days. Participants with suspected arrhythmias are followed up by study cardiologist who makes final diagnoses. Participants diagnosed with AF are initiated on treatment based on current anticoagulation guidelines and clinical reasoning. ANALYTICAL PLAN: Age-stratified and sex-stratified prevalence of AF in the Anand District will be calculated for sample and estimated for Anand distribution using survey design weights. Sociodemographic and clinical factors associated with AF will be evaluated using multivariable regression methods. Performance of each mobile technology in detecting AF will be evaluated using a 12-lead ECG interpretation as the gold standard. ETHICS AND DISSEMINATION: This protocol was approved separately by the Institutional Review Board of University of Massachusetts Medical School and the Human Research Ethics Committee at Charutar Arogya Mandal. The findings of this study will be disseminated through peer-reviewed journals and scientific conferences.

Society for Vascular Surgery Wound, Ischemia, foot Infection (WIfI) score correlates with the intensity of multimodal limb treatment and patient-centered outcomes in patients with threatened limbs managed in a limb preservation center.

OBJECTIVE: The Society for Vascular Surgery Wound, Ischemia, foot Infection (WIfI) system aims to stratify threatened limbs according to their anticipated natural history and estimate the likelihood of benefit from revascularization, but whether it accurately stratifies outcomes in limbs undergoing aggressive treatment for limb salvage is unknown. We investigated whether the WIfI stage correlated with the intensity of limb treatment required and patient-centered outcomes. METHODS: We stratified limbs from a prospectively maintained database of consecutive patients referred to a limb preservation center according to WIfI stage (October 2013-May 2015). Comorbidities, multimodal limb treatment, including foot operations and revascularization, and patient-centered outcomes (wound healing, limb salvage, amputation-free survival, maintenance of ambulatory and independent living status, and mortality) were compared among WIfI stages. Multivariate analysis was performed to identify predictors of wound healing and limb salvage. RESULTS: We identified 280 threatened limbs encompassing all WIfI stages in 257 consecutive patients: stage 1, 48 (17%); stage 2, 67 (24%); stage 3, 64 (23%); stage 4, 83 (30%); and stage 5 (unsalvageable), 18 (6%). Operative foot débridement, minor amputation, and use of revascularization increased with increasing WIfI stage (P ≤ .04). Revascularization was performed in 106 limbs (39%), with equal use of open and endovascular procedures. Over a median follow-up of 209 days (interquartile range, 95, 340) days, 1-year Kaplan-Meier wound healing cumulative incidence was 71%, and the proportion with complete wound healing decreased with increasing WIfI stage. Major amputation was required in 26 stage 1 to 4 limbs (10%). Increasing WIfI stage was associated with decreased 1-year Kaplan-Meier limb salvage (stage 1: 96%, stage 2: 84%, stage 3: 90%, and stage 4: 78%; P = .003) and amputation-free survival (P = .006). Stage 4 WIfI independently predicted amputation (hazard ratio, 12; 95% confidence interval, 1.6-94). Amputation rates in patients with severe Ischemia grade 3 were lower in those who underwent revascularization than in those who did not (14% vs 41%; P = .01) Ambulatory and independent living status at follow-up deteriorated significantly from baseline in stage 4 but not stage 1 to 3 patients. Mortality was not different between WIfI stages. CONCLUSIONS: In patients treated aggressively for limb salvage, WIfI stage correlated with intensity of multimodal limb treatment and with limb salvage and patient-centered outcomes at 1 year. Revascularization improved limb salvage in severe ischemia. These data support the Society for Vascular Surgery WIfI system as a powerful tool to risk-stratify patients with threatened limbs and guide treatment.