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.

High-Sensitivity Troponin I Levels and Coronary Artery Disease Severity, Progression, and Long-Term Outcomes.

BACKGROUND: The associations between high-sensitivity troponin I (hsTnI) levels and coronary artery disease (CAD) severity and progression remain unclear. We investigated whether there is an association between hsTnI and angiographic severity and progression of CAD and whether the predictive value of hsTnI level for incident cardiovascular outcomes is independent of CAD severity. METHODS AND RESULTS: In 3087 patients (aged 63±12 years, 64% men) undergoing cardiac catheterization without evidence of acute myocardial infarction, the severity of CAD was calculated by the number of major coronary arteries with ≥50% stenosis and the Gensini score. CAD progression was assessed in a subset of 717 patients who had undergone ≥2 coronary angiograms >3 months before enrollment. Patients were followed up for incident all-cause mortality and incident cardiovascular events. Of the total population, 11% had normal angiograms, 23% had nonobstructive CAD, 20% had 1-vessel CAD, 20% had 2-vessel CAD, and 26% had 3-vessel CAD. After adjusting for age, sex, race, body mass index, smoking, hypertension, diabetes mellitus history, and renal function, hsTnI levels were independently associated with the severity of CAD measured by the Gensini score (log 2 ß=0.31; 95% confidence interval, 0.18-0.44; P<0.001) and with CAD progression (log 2 ß=0.36; 95% confidence interval, 0.14-0.58; P=0.001). hsTnI level was also a significant predictor of incident death, cardiovascular death, myocardial infarction, revascularization, and cardiac hospitalizations, independent of the aforementioned covariates and CAD severity. CONCLUSIONS: Higher hsTnI levels are associated with the underlying burden of coronary atherosclerosis, more rapid progression of CAD, and higher risk of all-cause mortality and incident cardiovascular events. Whether more aggressive treatment aimed at reducing hsTnI levels can modulate disease progression requires further investigation.

Relation of Changes in Body Fat Distribution to Oxidative Stress.

Android fat is a surrogate measure of visceral obesity in the truncal region. Both visceral adiposity and oxidative stress (OS) are linked to cardiometabolic risk factors and clinical cardiovascular disease. However, whether body fat distribution (android vs gynoid) is associated with OS remains unknown. We hypothesized that increased android fat will be associated with greater OS. Body fat distribution and markers of OS, including plasma levels of reduced (cysteine and glutathione) and oxidized (cystine and glutathione disulfide) aminothiols, were estimated in 711 volunteers (67% female, 23% black, mean age 48 ± 11) enrolled in the Emory Georgia Tech Predictive Health study. At 1 year, 498 subjects had repeat testing. At baseline, anthropometric and fat distribution indexes, including body mass index, waist circumference, weight/hip ratio, and android and gynoid fat mass correlated with lower plasma concentrations of glutathione and higher cystine levels indicative of higher OS. At 1 year, the change in android but not gynoid fat mass or body mass index negatively correlated with the change in the plasma glutathione level after adjustment for cardiovascular risk factors. Increased body fat, specifically android fat mass, is an independent determinant of systemic OS, and its change is associated with a simultaneous change in OS, measured as plasma glutathione. In conclusion, our findings suggest that excess android or visceral fat contributes to the development of cardiovascular disease through modulating OS.

Association Between Living in Food Deserts and Cardiovascular Risk.

BACKGROUND: Food deserts (FD), neighborhoods defined as low-income areas with low access to healthy food, are a public health concern. We evaluated the impact of living in FD on cardiovascular risk factors and subclinical cardiovascular disease (CVD) with the hypothesis that people living in FD will have an unfavorable CVD risk profile. We further assessed whether the impact of FD on these measures is driven by area income, individual household income, or area access to healthy food. METHODS AND RESULTS: We studied 1421 subjects residing in the Atlanta metropolitan area who participated in the META-Health study (Morehouse and Emory Team up to Eliminate Health Disparities; n=712) and the Predictive Health study (n=709). Participants' zip codes were entered into the United States Food Access Research Atlas for FD status. Demographic data, metabolic profiles, hs-CRP (high-sensitivity C-reactive protein) levels, oxidative stress markers (glutathione and cystine), and arterial stiffness were evaluated. Mean age was 49.4 years, 38.5% male and 36.6% black. Compared with those not living in FD, subjects living in FD (n=187, 13.2%) had a higher prevalence of hypertension and smoking, higher body mass index, fasting glucose, and 10-year risk for CVD. They also had higher hs-CRP (P=0.014), higher central augmentation index (P=0.015), and lower glutathione level (P=0.003), indicative of increased oxidative stress. Area income and individual income, rather than food access, were associated with CVD risk measures. In a multivariate analysis that included food access, area income and individual income, both low-income area and low individual household income, were independent predictors of a higher 10-year risk for CVD. Only low individual income was an independent predictor of higher hs-CRP and augmentation index. CONCLUSIONS: Although living in FD is associated with a higher burden of cardiovascular risk factors and preclinical indices of CVD, these associations are mainly driven by area income and individual income rather than access to healthy food.

Circulating soluble urokinase plasminogen activator receptor levels and peripheral arterial disease outcomes.

BACKGROUND AND AIMS: Circulating soluble urokinase plasminogen activator receptor (suPAR) is a marker of immune activation associated with atherosclerosis. Whether suPAR levels are associated with prevalent peripheral arterial disease (PAD) and its adverse outcomes remains unknown and is the aim of the study. METHODS: SuPAR levels were measured in 5810 patients (mean age 63 years, 63% male, 77% with obstructive coronary artery disease [CAD]) undergoing cardiac catheterization. The presence of PAD (n = 967, 17%) was classified as carotid (36%), lower/upper extremities (30%), aortic (15%) and multisite disease (19%). Multivariable logistic and Cox regression models were used to determine independent predictors of prevalent PAD and outcomes including all-cause death, cardiovascular death and PAD-related events after adjustment for age, gender, race, body mass index, smoking, diabetes, hypertension, hyperlipidemia, renal function, heart failure history, and obstructive CAD. RESULTS: Plasma suPAR levels were 22.5% (p < 0.001) higher in patients with PAD compared to those without PAD. Plasma suPAR was higher in patients with more extensive PAD (≥2 compared to single site) p < 0.001. After multivariable adjustment, suPAR was associated with prevalent PAD; odds ratio (OR) for highest compared to lowest tertile of 2.0, 95% CI (1.6-2.5) p < 0.001. In Cox survival analyses adjusted for clinical characteristics and medication regimen, suPAR (in the highest vs. lowest tertile) remained an independent predictor of all-cause death [HR 3.1, 95% CI (1.9-5.3)], cardiovascular death [HR 3.5, 95% CI (1.8-7.0)] and PAD-related events [HR = 1.8, 95% CI (1.3-2.6) p < 0.001 for all]. CONCLUSIONS: Plasma suPAR level is predictive of prevalent PAD and of incident cardiovascular and PAD-related events. Whether SuPAR measurement can help screen, risk stratify, or monitor therapeutic responses in PAD requires further investigation.

Telomere Shortening, Regenerative Capacity, and Cardiovascular Outcomes.

RATIONALE: Leukocyte telomere length (LTL) is a biological marker of aging, and shorter LTL is associated with adverse cardiovascular outcomes. Reduced regenerative capacity has been proposed as a mechanism. Bone marrow-derived circulating progenitor cells are involved in tissue repair and regeneration. OBJECTIVE: Main objective of this study was to examine the relationship between LTL and progenitor cells and their impact on adverse cardiovascular outcomes. METHODS AND RESULTS: We measured LTL by quantitative polymerase chain reaction in 566 outpatients (age: 63±9 years; 76% men) with coronary artery disease. Circulating progenitor cells were enumerated by flow cytometry. After adjustment for age, sex, race, body mass index, smoking status, and previous myocardial infarction, a shorter LTL was associated with a lower CD34+ cell count: for each 10% shorter LTL, CD34+ levels were 5.2% lower (P<0.001). After adjustment for the aforementioned factors, both short LTL (

Pulmonary vein anatomy assessed by cardiac magnetic resonance imaging in patients undergoing initial atrial fibrillation ablation: implications for novel ablation technologies.

BACKGROUND: Novel atrial fibrillation (AF) ablation tools have been designed to facilitate "single-shot" pulmonary vein (PV) isolation using multi-electrode or balloon-based catheters. However, in contrast to point-by-point radiofrequency ablation, these tools may be more dependent on suitable PV anatomy to achieve circumferential PV isolation. METHODS: Three hundred and twenty-two patients underwent gadolinium-enhanced cardiac magnetic resonance angiography to delineate PV anatomy prior to initial AF ablation. Long (a) and short (b) axis measurements of the PV orifice were used to calculate the eccentricity index of the PV ostium. RESULTS: Long axis dimensions of the left superior PV were 18.2 ± 3.3 mm, left inferior PV 17.7 ± 3.9 mm, right superior PV (RSPV) 20.4 ± 4.3, and right inferior PV 18.7 ± 4.7 mm. The long axis dimension of the RSPV was significantly larger than other PVs (p < 0.001). Forty-two patients (13 %) had at least one PV with a long axis dimension >25 mm and 16 patients (5 %) had at least one PV with a long axis dimension >28 mm. Left-sided PV ostia were significantly more ellipse-shaped than the right-sided PVs, which tended to be more spherical. A significant positive correlation was noted between increasing PV size and increased orifice eccentricity. CONCLUSIONS: In this large cohort undergoing initial AF ablation, over 10 % of patients had at least one standard PV with a dimension >25 mm. Additionally, significant differences were noted between left- and right-sided veins with regard to orifice eccentricity. These findings have implications for the design of AF ablation tools and may account for differential isolation rates between PVs noted in some recent studies of novel ablation technologies.

Mobile Health Initiatives to Improve Outcomes in Primary Prevention of Cardiovascular Disease.

OPINION STATEMENT: Cardiovascular disease affects more than a third of American adults and is the leading cause of mortality in the USA. Over the last 40 years, several behavioral and medical risk factors have been recognized as major contributors to cardiovascular disease. Effective management of many of these risk factors, particularly behavioral risk factors, remains challenging. With the growth of mobile health (mHealth) technology, a variety of novel strategies are now available to facilitate the delivery of interventions directed at reducing these risk factors. In this review, we discuss recent clinical studies and technologic innovations leveraging smartphone devices, social media, and wearable health tracking devices to facilitate behavioral interventions directed at three important and highly prevalent behavioral risk factors for cardiovascular disease: smoking, physical inactivity, and sub-optimal nutrition. We believe this technology has significant potential to provide low-cost, scalable, and individualized tools to improve management of these important cardiovascular disease risk factors.

Outcome of Subcutaneous Implantable Cardioverter Defibrillator Implantation in Patients with End-Stage Renal Disease on Dialysis.

BACKGROUND: Although the subcutaneous ICD (S-ICD®) is an attractive alternative in patients with end-stage renal disease (ESRD), data on S-ICD outcomes in dialysis patients are lacking. METHODS: Patients with cardiomyopathy undergoing S-ICD implantation in our center were stratified by need for chronic dialysis at the time of implant. The primary endpoint was incidence of death, heart failure hospitalization or appropriate S-ICD shocks, and secondary endpoints were incidence of inappropriate shocks or implant related complications requiring surgical re-intervention. Mean follow-up was longer in the nondialysis cohort (514 ± 495 vs. 227 ± 233 days, P = 0.006), so all endpoints were analyzed using time-dependent comparisons and reported as annual event rates. RESULTS: Out of 79 S-ICD implants included in this analysis, 27 patients were on dialysis. Dialysis patients were older and more likely to be diabetic. Mean ejection fraction across the entire cohort was 26.9% without significant difference between dialysis and nondialysis groups. Although not significant, the incidence of the primary endpoint was higher in the dialysis cohort (23.8%/year vs. 10.9%/year, P = 0.317), driven primarily by a higher rate of appropriate shocks. The rate of inappropriate shocks was similar between groups (dialysis 6.0%/year vs. nondialysis 6.8%/year, P = 0.509). No patients in the dialysis cohort had complications requiring surgical re-intervention versus 6 patients in the nondialysis cohort (P = 0.086). CONCLUSIONS: Our data suggest that S-ICD implantation in dialysis patients is not associated with an excess risk of implant related complications or inappropriate shocks.

Long-term survival for patients with metabolic syndrome after bioprosthetic or mechanical valve replacement.

BACKGROUND: Metabolic diseases are thought to negatively impact the long-term survival of cardiac patients and have been shown to be associated with reduced durability of bioprosthetic heart valves. The purpose of this study is to determine whether long-term survival of post-valve replacement patients is affected by the presence of metabolic disease, and whether choice of tissue versus mechanical prosthesis impacts survival. METHODS: A retrospective review was conducted of all isolated valve replacements performed between 2002 and 2011 from the STS adult cardiac database of Emory Healthcare Hospitals. A total of 1,222 cases were reviewed, of which 909 patients had AVR (661 tissue, 248 mechanical), and 313 MVR (190 tissue, 123 mechanical). Cardiometabolic syndrome (CMS), in accordance with the World Health Organization (WHO) definition, was present in 242 of 1,222 (19.8%) cases in entire cohort, 203 of 909 (22.3%) in AVR, and 39 of 313 (12.5%) in MVR. Cox proportional hazard regression analysis was used to calculate long-term survival after adjusting for propensity score (PS), Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM), and direct covariates for valve and implant type and stratifying by CMS. RESULTS: In PS adjusted AVR, patients with CMS risk factors had worse survival compared to metabolic risk-free patients (AHR = 3.47), as was the case for MVR (AHR = 4.06). Tissue MVR patients with CMS had higher hazard of death compared to patients with no diabetes and no metabolic risk factors after adjusting for PROM (AHR = 3.33) and direct covariates (AHR = 3.91). CONCLUSIONS: Metabolic diseases negatively impact long-term survival of aortic and mitral valve replacement (MVR) patients. Tissue prostheses are associated with worse long-term survival following MVR.