ABSTRACT
PURPOSE OF THE REVIEW: This review aims to assess the variability in considering hypercholesterolemia for cardiovascular risk stratification in the general population. Recent literature on the integration of hypercholesterolemia into clinical risk scores and its interaction with other risk factors will be explored. RECENT FINDINGS: The impact of hypercholesterolemia on risk estimation varies among different cardiovascular risk calculators. Elevated lipid levels during early life stages contribute to atherosclerotic plaque development, influencing disease severity despite later treatment initiation. The interplay between low-density lipoprotein cholesterol (LDLc), inflammatory markers and non-LDL lipid parameters enhances cardiovascular risk stratification. Studies have also examined the role of coronary artery calcium (CAC) score as a negative risk marker in populations with severe hypercholesterolemia. Furthermore, polygenic risk scores (PRS) may aid in diagnosing non-monogenic hypercholesterolemia, refining cardiovascular risk stratification and guiding lipid-lowering therapy strategies. Understanding the heterogeneity in risk estimation and the role of emerging biomarkers and imaging techniques is crucial for optimizing cardiovascular risk prediction and guiding personalized treatment strategies in individuals with hypercholesterolemia.
Subject(s)
Cardiovascular Diseases , Hypercholesterolemia , Humans , Hypercholesterolemia/complications , Hypercholesterolemia/epidemiology , Hypercholesterolemia/diagnosis , Risk Assessment/methods , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/etiology , Heart Disease Risk Factors , Biomarkers/blood , Cholesterol, LDL/blood , Risk FactorsABSTRACT
PURPOSE OF REVIEW: Dyslipidemia and type 2 diabetes mellitus are two common conditions that are associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD). In this review, we aimed to provide an in-depth and contemporary review of non-invasive approaches to assess subclinical atherosclerotic burden, predict cardiovascular risk, and guide appropriate treatment strategies. We focused this paper on two main imaging modalities: coronary artery calcium (CAC) score and computed tomography coronary angiography. RECENT FINDINGS: Recent longitudinal studies have provided stronger evidence on the relationship between increased CAC, thoracic aorta calcification, and risk of cardiovascular events among those with primary hypercholesterolemia, highlighting the beneficial role of statin therapy. Interestingly, resilient profiles of individuals not exhibiting atherosclerosis despite dyslipidemia have been described. Non-conventional markers of dyslipidemia have also been associated with increased subclinical atherosclerosis presence and burden, highlighting the contribution of apolipoprotein B-100 (apoB)-rich lipoprotein particles, such as remnant cholesterol and lipoprotein(a), to the residual risk of individuals on-target for low-density lipoprotein cholesterol (LDL-C) goals. Regarding type 2 diabetes mellitus, variability in atherosclerotic burden has also been found, and CAC testing has shown significant predictive value in stratifying cardiovascular risk. Non-invasive assessment of subclinical atherosclerosis can help reveal the continuum of ASCVD risk in those with dyslipidemia and diabetes mellitus and can inform personalized strategies for cardiovascular disease prevention in the primary prevention setting.
Subject(s)
Atherosclerosis , Diabetes Mellitus, Type 2 , Dyslipidemias , Humans , Dyslipidemias/complications , Dyslipidemias/drug therapy , Diabetes Mellitus, Type 2/complications , Atherosclerosis/diagnosis , Computed Tomography Angiography , Coronary Angiography/methodsABSTRACT
The Food and Drug Administration recommends prognostic enrichment of randomized controlled trials (RCTs), aimed at restricting the study population to participants most likely to have events and therefore derive benefit from a given intervention. The coronary artery calcium (CAC) score is powerful discriminator of cardiovascular risk, and in this review we discuss how CAC may be used to augment widely used prognostic enrichment paradigms of RCTs of add-on therapies in primary prevention. We describe recent studies in this space, with special attention to the ability of CAC to further stratify risk among guideline-recommended candidates for add-on risk-reduction therapies. Given the potential benefits in terms of sample size, cost reduction, and overall RCT feasibility of a CAC-based enrichment strategy, we discuss approaches that may help maximize its advantages while minimizing logistical barriers and other challenges. Specifically, use of already existing CAC data to avoid the need to re-scan participants with previously documented high CAC scores, use of increasingly available, large clinical CAC databases to facilitate the identification of potential RCT participants, and implementation of machine learning approaches to measure CAC in existing computed tomography images performed for other purposes, will most likely boost the implementation of a CAC-based enrichment paradigm in future RCTs.
Subject(s)
Calcium , Coronary Artery Disease , Coronary Angiography , Coronary Artery Disease/epidemiology , Coronary Vessels/diagnostic imaging , Humans , Randomized Controlled Trials as Topic , Risk Assessment/methods , Risk FactorsABSTRACT
PURPOSE OF REVIEW: The high variability of cardiovascular risk in heterozygous familial hypercholesterolemia (HeFH) is a challenge for therapeutical management. Subclinical cardiovascular imaging represents a tool to overcome this challenge. The purpose of this review is to update the reader on the most recent findings on the non-invasive detection of atherosclerotic burden by carotid doppler ultrasound (US), coronary artery calcium (CAC) score, and computed tomography coronary angiography (CTCA) for the optimization of risk stratification in HeFH subjects. RECENT FINDINGS: Carotid ultrasound (US) proved its efficacy in the long-term follow-up of HeFH children treated early on with statins, showing a significant reduction of atherosclerotic progression compared to untreated unaffected siblings. The added value of CAC score has been confirmed to predict the risk of cardiovascular events and improve risk stratification provided by available risk equations in asymptomatic HeFH subjects from large prospective cross-national cohorts. Additionally, CTCA provides detailed information on plaque quality and stability, but its role in primary prevention HeFH subjects needs to be further explored. Cardiovascular imaging for the detection of subclinical atherosclerotic cardiovascular disease in HeFH is a promising tool to improve diagnostic and therapeutical management of this undertreated and late-diagnosed disease.
Subject(s)
Atherosclerosis , Coronary Artery Disease , Hydroxymethylglutaryl-CoA Reductase Inhibitors , Hypercholesterolemia , Hyperlipoproteinemia Type II , Atherosclerosis/diagnostic imaging , Carotid Arteries , Child , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/etiology , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use , Hyperlipoproteinemia Type II/complications , Hyperlipoproteinemia Type II/diagnosis , Hyperlipoproteinemia Type II/genetics , Prospective Studies , Risk FactorsABSTRACT
INTRODUCTION: Rates of injection-drug use associated infective endocarditis (IDU-IE) are rising, and most patients with IDU-IE do not receive addiction care during hospitalization. We sought to characterize cardiac surgeons' practices and attitudes toward patients with IDU-IE due to their integral role treating them. METHODS: This is a survey of 201 cardiac surgeons in the U.S who were asked about the addiction care they engage for patients with IDU-IE along with questions pertaining to stigma against people who use drugs (PWUD). Descriptive statistics and multivariable logistic regression were used to identify patterns in surgeons' practices and determine associations between attitudes toward substance use disorder (SUD) and beliefs about medications for opioid use disorder (MOUD). RESULTS: A minority of surgeons have access to specialty addiction services (35%) in their hospital, but when available 93% consult them for patients with IDU-IE. A quarter of surgeons reported thinking that SUD is a choice and do not believe MOUD have a role in reducing IDU-IE recurrence. Conversely, 69% of surgeons agreed with the disease model of addiction and were four times more likely to believe that MOUD has a role in reducing IDU-IE recurrence (aOR 4.09, 95% CI 1.8-9.27, p = 0.001). CONCLUSION: Access to addiction specialists is limited in most hospital settings, but when available, most surgeons report consulting them and supporting MOUD. However, a significant proportion of surgeons hold non-evidence-based attitudes toward SUD and PWUD. This suggests that lack of education and stigma may affect the care of patients with IDU-IE, highlighting the need for education about, and destigmatization of addiction within health systems.
Subject(s)
Attitude of Health Personnel , Cardiology , Opioid-Related Disorders , Substance Abuse, Intravenous , Surgeons , Humans , Opioid-Related Disorders/psychology , Opioid-Related Disorders/therapy , Retrospective Studies , Substance Abuse, Intravenous/psychology , Substance Abuse, Intravenous/therapy , Surgeons/psychologyABSTRACT
BACKGROUND AND PURPOSE: Despite declining stroke rates in the general population, stroke incidence and hospitalizations are rising among younger individuals. Awareness of and prompt response to stroke symptoms are crucial components of a timely diagnosis and disease management. We assessed awareness of stroke symptoms and response to a perceived stroke among young adults in the United States. METHODS: Using data from the 2017 National Health Interview Survey, we assessed awareness of 5 common stroke symptoms and the knowledge of planned response (ie, calling emergency medical services) among young adults (<45 years) across diverse sociodemographic groups. Common stroke symptoms included: (1) numbness of face/arm/leg, (2) confusion/trouble speaking, (3) difficulty walking/dizziness/loss of balance, (4) trouble seeing in one/both eyes, and (5) severe headache. RESULTS: Our study population included 24 769 adults, of which 9844 (39.7%) were young adults who were included in our primary analysis, and represented 107.2 million US young adults (mean age 31.3 [±7.5] years, 50.6% women, and 62.2% non-Hispanic White). Overall, 2718 young adults (28.9%) were not aware of all 5 stroke symptoms, whereas 242 individuals (2.7%; representing 2.9 million young adults in the United States) were not aware of a single symptom. After adjusting for confounders, Hispanic ethnicity (odds ratio, 1.96 [95% CI, 1.17-3.28]), non-US born immigration status (odds ratio, 2.02 [95% CI, 1.31-3.11]), and lower education level (odds ratio, 2.77 [95% CI, 1.76-4.35]), were significantly associated with lack of symptom awareness. Individuals with 5 high-risk characteristics (non-White, non-US born, low income, uninsured, and high school educated or lower) had nearly a 4-fold higher odds of not being aware of all symptoms (odds ratio, 3.70 [95% CI, 2.43-5.62]). CONCLUSIONS: Based on data from the National Health Interview Survey, a large proportion of young adults may not be aware of stroke symptoms. Certain sociodemographic subgroups with decreased awareness may benefit from focused public health interventions.
Subject(s)
Ethnicity/statistics & numerical data , Health Knowledge, Attitudes, Practice , Insurance, Health/statistics & numerical data , Stroke/physiopathology , Adult , Black or African American/statistics & numerical data , Awareness , Educational Status , Emigrants and Immigrants/statistics & numerical data , Female , Hispanic or Latino/statistics & numerical data , Humans , Income/statistics & numerical data , Male , Medically Uninsured/statistics & numerical data , United States , White People/statistics & numerical dataSubject(s)
Coronary Artery Disease , Hyperlipoproteinemia Type II , Vascular Calcification , Clinical Decision-Making , Coronary Artery Disease/diagnosis , Coronary Artery Disease/etiology , Coronary Artery Disease/therapy , Humans , Hyperlipoproteinemia Type II/complications , Hyperlipoproteinemia Type II/diagnosis , Hyperlipoproteinemia Type II/therapy , Risk Assessment , Vascular Calcification/diagnosis , Vascular Calcification/etiology , Vascular Calcification/therapyABSTRACT
BACKGROUND: The study aims to compare cost and non-cost factors associated with delays in receiving medical care in adults with atherosclerotic cardiovascular disease (ASCVD). METHODS: Using 2014-2018 data from the Centers for Disease Control and Prevention (CDC) Behaviour Risk Factor Surveillance System (BRFSS) survey (N = 508,203), multivariate logistic regression models were developed to compute the adjusted odds ratio of reasons for delays in medical care in adults with ASCVD. RESULTS: Our study population of 61,227 adults with ASCVD (9.1%) had higher odds of any medical care delay (aOR 1.50, 95% CI 1.43-1.57), delay due to cost (aOR 1.55, 95% CI 1.45-1.65), long clinic wait times (aOR 1.21, 95% CI 1.04-1.39) and lack of transportation (aOR 1.64, 95% CI 1.47-1.84) than those without ASCVD. CONCLUSION: Novel public health and health policy approaches are urgently needed to reduce the cost- and non-cost-related barriers that adults with ASCVD encounter when accessing healthcare services.
Subject(s)
Atherosclerosis , Humans , Male , Female , Middle Aged , Atherosclerosis/economics , Aged , Adult , Health Services Accessibility/economics , Time-to-Treatment/economics , Time-to-Treatment/statistics & numerical data , United States , Behavioral Risk Factor Surveillance System , Health Care Costs/statistics & numerical data , Logistic ModelsABSTRACT
Importance: Hypertension remains a leading factor associated with cardiovascular disease, and demographic and socioeconomic disparities in blood pressure (BP) control persist. While advances in digital health technologies have increased individuals' access to care for hypertension, few studies have analyzed the use of digital health interventions in vulnerable populations. Objective: To assess the association between digital health interventions and changes in BP and to characterize tailored strategies for populations experiencing health disparities. Data Sources: In this systematic review and meta-analysis, a systematic search identified studies evaluating digital health interventions for BP management in the Cochrane Library, Ovid Embase, Google Scholar, Ovid MEDLINE, PubMed, Scopus, and Web of Science databases from inception until October 30, 2023. Study Selection: Included studies were randomized clinical trials or cohort studies that investigated digital health interventions for managing hypertension in adults; presented change in systolic BP (SBP) or baseline and follow-up SBP levels; and emphasized social determinants of health and/or health disparities, including a focus on marginalized populations that have historically been underserved or digital health interventions that were culturally or linguistically tailored to a population with health disparities. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Data Extraction and Synthesis: Two reviewers extracted and verified data. Mean differences in BP between treatment and control groups were analyzed using a random-effects model. Main Outcomes and Measures: Primary outcomes included mean differences (95% CIs) in SBP and diastolic BP (DBP) from baseline to 6 and 12 months of follow-up between digital health intervention and control groups. Shorter- and longer-term follow-up durations were also assessed, and sensitivity analyses accounted for baseline BP levels. Results: A total of 28 studies (representing 8257 participants) were included (overall mean participant age, 57.4 years [range, 46-71 years]; 4962 [60.1%], female). Most studies examined multicomponent digital health interventions incorporating remote BP monitoring (18 [64.3%]), community health workers or skilled nurses (13 [46.4%]), and/or cultural tailoring (21 [75.0%]). Sociodemographic characteristics were similar between intervention and control groups. Between the intervention and control groups, there were statistically significant mean differences in SBP at 6 months (-4.24 mm Hg; 95% CI, -7.33 to -1.14 mm Hg; P = .01) and SBP changes at 12 months (-4.30 mm Hg; 95% CI, -8.38 to -0.23 mm Hg; P = .04). Few studies (4 [14.3%]) reported BP changes and hypertension control beyond 1 year. Conclusions and Relevance: In this systematic review and meta-analysis of digital health interventions for hypertension management in populations experiencing health disparities, BP reductions were greater in the intervention groups compared with the standard care groups. The findings suggest that tailored initiatives that leverage digital health may have the potential to advance equity in hypertension outcomes.
Subject(s)
Digital Health , Hypertension , Telemedicine , Female , Humans , Male , Middle Aged , Healthcare Disparities/statistics & numerical data , Hypertension/therapy , Hypertension/prevention & control , United StatesABSTRACT
BACKGROUND: The association of hospital and physician procedure volume with outcome has not been well evaluated for atrial fibrillation (AF) ablation in contemporary practice. OBJECTIVE: This study aimed to determine the association between hospital and physician AF ablation volume and procedural success (isolation of all pulmonary veins) and major adverse events (MAEs). METHODS: Procedures reported to the National Cardiovascular Data Registry AFib Ablation Registry between July 2019 and June 2022 were included. Hospital and physician procedural volumes were annualized and stratified into quartiles to compare outcomes. Three-level hierarchical (patient, hospital, and physician) models were used to assess the procedural volume-outcome relationship. RESULTS: A total of 70,296 first-time AF ablations at 186 US hospitals were included. Overall, procedural success and MAE rates were 98.5% and 1.0%, respectively. With hospital volume (Q4) as a reference, the likelihood of procedural success was lower for Q1 (odds ratio [OR], 0.44; 95% CI, 0.29-0.68), Q2 (OR, 0.50; 95% CI, 0.33-0.75), and Q3 (OR, 0.60; 95% CI, 0.40-0.89); the results were similarly significant for physician volume. With MAE for hospitals, there was an inverse procedural volume relationship for Q1 (OR, 1.78; 95% CI, 1.26-2.52) but not for Q2 (OR, 1.06; 95% CI, 0.77-1.46) or Q3 (OR, 1.19; 95% CI, 0.89-1.58) and similarly for physicians in Q1 and Q2 but not in Q3. An adjusted MAE ≤1% was predicted by an annual volume of approximately 190 for hospitals and 60 for physicians. CONCLUSION: In this national cohort, hospital and physician AF ablation procedural volumes were directly related to acute procedural success and inversely related to rates of MAE.
ABSTRACT
BACKGROUND: Elevated levels of lipoprotein(a) (Lp(a)) are independently associated with an increased risk of atherosclerotic cardiovascular disease events. However, the mechanisms driving this association are poorly understood. We aimed to evaluate the association between Lp(a) and coronary plaque characteristics in a contemporary US cohort without clinical atherosclerotic cardiovascular disease, undergoing coronary computed tomography angiography, the noninvasive gold standard for the assessment of coronary atherosclerosis. METHODS: We used baseline data from the Miami Heart Study-a community-based, prospective cohort study-which included asymptomatic adults aged 40 to 65 years evaluated using coronary computed tomography angiography. Those taking any lipid-lowering therapies were excluded. Elevated Lp(a) was defined as ≥125 nmol/L. Outcomes included any plaque, coronary artery calcium score >0, maximal stenosis ≥50%, presence of any high-risk plaque feature (positive remodeling, spotty calcification, low-attenuation plaque, napkin ring), and the presence of ≥2 high-risk plaque features. RESULTS: Among 1795 participants (median age, 52 years; 54.3% women; 49.6% Hispanic), 291 (16.2%) had Lp(a) ≥125 nmol/L. In unadjusted analyses, individuals with Lp(a) ≥125 nmol/L had a higher prevalence of all outcomes compared with Lp(a) <125 nmol/L, although differences were only statistically significant for the presence of any coronary plaque and ≥2 high-risk features. In multivariable models, elevated Lp(a) was independently associated with the presence of any coronary plaque (odds ratio, 1.40, [95% CI, 1.05-1.86]) and with ≥2 high-risk features (odds ratio, 3.94, [95% CI, 1.82-8.52]), although only 35 participants had this finding. Among participants with a coronary artery calcium score of 0 (n=1200), those with Lp(a) ≥125 nmol/L had a significantly higher percentage of any plaque compared with those with Lp(a) <125 nmol/L (24.2% versus 14.2%; P<0.001). CONCLUSIONS: In this contemporary analysis, elevated Lp(a) was independently associated with the presence of coronary plaque. Larger studies are needed to confirm the strong association observed with the presence of multiple high-risk coronary plaque features.
Subject(s)
Asymptomatic Diseases , Biomarkers , Computed Tomography Angiography , Coronary Angiography , Coronary Artery Disease , Lipoprotein(a) , Plaque, Atherosclerotic , Humans , Middle Aged , Female , Male , Lipoprotein(a)/blood , Florida/epidemiology , Prospective Studies , Coronary Angiography/methods , Coronary Artery Disease/epidemiology , Coronary Artery Disease/blood , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/diagnosis , Adult , Biomarkers/blood , Aged , Risk Factors , Coronary Vessels/diagnostic imaging , Up-Regulation , Predictive Value of Tests , Risk Assessment , Prevalence , Vascular Calcification/diagnostic imaging , Vascular Calcification/epidemiology , Vascular Calcification/bloodABSTRACT
Objectives: Individuals with familial hypercholesterolemia (FH) are at an increased risk for coronary artery disease (CAD). While prior research has shown variability in coronary artery calcification (CAC) among those with FH, studies with small sample sizes and single-center recruitment have been limited in their ability to characterize CAC and plaque burden in subgroups based on age and sex. Understanding the spectrum of atherosclerosis may result in personalized risk assessment and tailored allocation of costly add-on, non-statin lipid-lowering therapies. We aimed to characterize the presence and burden of CAC and coronary plaque on computed tomography angiography (CTA) across age- and sex-stratified subgroups of individuals with FH who were without CAD at baseline. Methods: We pooled 1,011 patients from six cohorts across Brazil, France, the Netherlands, Spain, and Australia. Our main measures of subclinical atherosclerosis included CAC ranges (i.e., 0, 1-100, 101-400, >400) and CTA-derived plaque burden (i.e., no plaque, non-obstructive CAD, obstructive CAD). Results: Ninety-five percent of individuals with FH (mean age: 48 years; 54% female; treated LDL-C: 154 mg/dL) had a molecular diagnosis and 899 (89%) were on statin therapy. Overall, 423 (42%) had CAC=0, 329 (33%) had CAC 1-100, 160 (16%) had CAC 101-400, and 99 (10%) had CAC >400. Compared to males, female patients were more likely to have CAC=0 (48% [n = 262] vs 35% [n = 161]) and no plaque on CTA (39% [n = 215] vs 26% [n = 120]). Among patients with CAC=0, 85 (20%) had non-obstructive CAD. Females also had a lower prevalence of obstructive CAD in CAC 1-100 (8% [n = 15] vs 18% [n = 26]), CAC 101-400 (32% [n = 22] vs 40% [n = 36]), and CAC >400 (52% [n = 16] vs 65% [n = 44]). Female patients aged 50-59 years were less likely to have obstructive CAD in CAC >400 (55% [n = 6] vs 70% [n = 19]). Conclusion: In this large, multi-national study, we found substantial age- and sex-based heterogeneity in CAC and plaque burden in a cohort of predominantly statin-treated individuals with FH, with evidence for a less pronounced increase in atherosclerosis among female patients. Future studies should examine the predictors of resilience to and long-term implications of the differential burden of subclinical coronary atherosclerosis in this higher risk population.
ABSTRACT
Hypertriglyceridemia (HTG) is a prevalent medical condition in patients with cardiometabolic risk factors and is associated with an increased risk of atherosclerotic cardiovascular disease (ASCVD), if left undiagnosed and undertreated. Current guidelines identify HTG as a risk-enhancing factor and, as a result, recommend clinical evaluation and lifestyle-based interventions to address potential secondary causes of elevated triglyceride (TG) levels. For individuals with mild to moderate HTG at risk of ASCVD, statin therapy alone or in combination with other lipid-lowering medications known to decrease ASCVD risk are guideline-endorsed. In addition to lifestyle modifications, patients with severe HTG at risk of acute pancreatitis may benefit from fibrates, mixed formulation omega-3 fatty acids, and niacin; however, evidence does not support their use for ASCVD risk reduction in the contemporary statin era. Novel therapeutics including those that target apoC-III and ANGPTL3 have shown to be safe, well-tolerated, and effective for lowering TG levels. Given the growing burden of cardiometabolic disease and risk factors, public health and health policy strategies are urgently needed to enhance access to effective pharmacotherapies, affordable and nutritious food options, and timely health care services.
ABSTRACT
OBJECTIVE: Older, relatively small studies identified female sex as a risk factor for adverse events after catheter ablation for atrial fibrillation (AF). We aimed to assess contemporary sex-based differences in baseline and procedural characteristics, adverse events, and quality of life among adults undergoing catheter ablation for AF. METHODS: In this observational cohort study, we evaluated those enrolled in the National Cardiovascular Data Registry AFib Ablation Registry between January 2016 and September 2020. Using logistic regression, we analysed the association between patient sex and in-hospital adverse events. RESULTS: Among 58 960 adults (34.6% women) from 150 centres undergoing AF ablation by 706 physicians, women were older (68 vs 64 years, p<0.001), had more comorbidities, and had lower AF-related quality of life at the time of ablation (mean Atrial Fibrillation Effect on QualiTy-of-life Questionnaire) score: 51.8 vs 62.2, p<0.001). Women had a higher risk of hospitalisation >1 day (adjusted OR (aOR) 1.41 (95% CI 1.33 to 1.49)), major adverse event (aOR 1.60 (95% CI 1.33 to 1.92)) and any adverse event (aOR 1.57 (95% CI 1.41 to 1.75)). Women had a higher risk of bradycardia requiring pacemaker, phrenic nerve damage, pericardial effusion, bleeding and vascular injury, but had no differences in death or acute pulmonary vein isolation. CONCLUSIONS: Among almost 60 000 patients in the largest prospective registry of AF ablation procedures, female sex was independently associated with a higher risk of hospitalisation >1 day, adverse events, and reduced quality of life, although there were no differences in death or acute pulmonary vein isolation.
Subject(s)
Atrial Fibrillation , Catheter Ablation , Adult , Humans , Female , Male , Atrial Fibrillation/surgery , Atrial Fibrillation/etiology , Quality of Life , Cohort Studies , Lung , Catheter Ablation/adverse effects , Treatment OutcomeABSTRACT
BACKGROUND: In randomized trials in women with breast cancer, exercise has been shown to have beneficial effects on cancer-related circulating biomarkers that may impact survival. Such studies are lacking for ovarian cancer. METHODS: This secondary analysis of a published randomized controlled trial examined the impact of a 6-month exercise intervention versus attention-control on change in prespecified circulating biomarkers (cancer antigen 125 (CA-125), C-reactive protein (CRP), insulin-like growth factor-1(IGF-1), insulin and leptin) in a subset of participants who provided a fasting blood draw (N = 104/144) at enrollment and at 6 months. Change in biomarkers between study arms was compared using a linear mixed effects model analysis. An exploratory analysis of the exercise intervention versus attention-control on all-cause mortality included all (N = 144) participants. All statistical tests were two-sided. RESULTS: Participants included in the biomarker analysis were 57.0 ± 8.8 (mean ± SD) years old and 1.6 ± 0.9 years post-diagnosis. Adherence to the exercise intervention was 176.4 ± 63.5 min/week. Post intervention IGF-1 (group difference in change: -14.2 (-26.1 to -2.3) ng/mL (least squared means (95% CI))) and leptin (-8.9 (-16.5 to -1.4) ng/mL) were significantly reduced in the exercise group (N = 53) compared to those in attention-control (N = 51). No group difference in change was seen for CA-125 (p = 0.54), CRP (p = 0.95), or insulin (p = 0.37). With median follow-up of 70 months [range 6.6-105.4 months], 50/144 (34.7%) (exercise group; 24/74 (32.4%) versus attention-control group; 26/70 (37.1%)) participants died with no between group difference in overall survival (p = 0.99). CONCLUSIONS: Further studies are needed to determine the clinical significance of exercise-induced changes in cancer-related circulating biomarkers in women with ovarian cancer.
Subject(s)
Breast Neoplasms , Ovarian Neoplasms , Humans , Female , Biomarkers, Tumor , Insulin-Like Growth Factor I , Leptin , Biomarkers , C-Reactive Protein/analysis , Ovarian Neoplasms/therapy , Insulin/metabolismABSTRACT
Genetic lipid disorders, ranging from common dyslipidemias such as familial hypercholesterolemia, lipoprotein (a), and familial combined hyperlipidemia to rare disorders including familial chylomicronemia syndrome and inherited hypoalphalipoproteinemias (ie, Tangier and fish eye diseases), affect millions of individuals in the United States and tens of millions around the world and are often undiagnosed in the general population. Clinicians should take into consideration the potential of inherited lipid disorders or syndromes when severe derangements in lipid parameters are observed. Patients' combined genotype and phenotype should be evaluated in conjunction with a host of environmental factors impacting their risk of atherosclerotic cardiovascular disease.
Subject(s)
Atherosclerosis , Cardiovascular Diseases , Dyslipidemias , Hyperlipoproteinemia Type I , Atherosclerosis/diagnosis , Atherosclerosis/epidemiology , Atherosclerosis/genetics , Cardiovascular Diseases/complications , Dyslipidemias/epidemiology , Dyslipidemias/genetics , Humans , Hyperlipoproteinemia Type I/complications , Lipids , Risk Factors , United States/epidemiologyABSTRACT
Background Suboptimal cardiovascular health (CVH) and social determinants of health (SDOH) have a significant impact on maternal morbidity and mortality. We aimed to evaluate the association of SDOH with suboptimal CVH among pregnant women in the United States. Methods and Results We examined cross-sectional data of pregnant women aged 18 to 49 years from the National Health Interview Survey (2013-2017). We ascertained optimal and suboptimal CVH based on the presence of 0 to 1 and ≥2 risk factors (hypertension, diabetes, hyperlipidemia, current smoking, obesity, and insufficient physical activity), respectively. We calculated an aggregate SDOH score representing 38 variables from 6 domains (economic stability; neighborhood, physical environment, and social cohesion; community and social context; food; education; and healthcare system) and divided into quartiles. We used Poisson regression model to evaluate the association of SDOH with suboptimal CVH and risk factors. Our study included 1433 pregnant women (28.8±5.5 years, 13% non-Hispanic Black). Overall, 38.4% (95% CI, 33.9-43.0) had suboptimal CVH versus 51.7% (95% CI, 47.0-56.3) among those in the fourth SDOH quartile. Risk ratios of suboptimal CVH, smoking, obesity, and insufficient physical activity were 2.05 (95% CI, 1.46-2.88), 8.37 (95% CI, 3.00-23.43), 1.54 (95% CI, 1.17-2.03), and 1.19 (95% CI, 1.01-1.42), respectively among those in the fourth SDOH quartile compared with the first quartile. Conclusions Over 50% of pregnant women with the highest SDOH burden had suboptimal CVH, highlighting the public health urgency for interventions in socially disadvantaged pregnant women with renewed strategies toward improving modifiable risk factors, especially smoking and insufficient physical activity.
Subject(s)
Cardiovascular Diseases , Social Determinants of Health , Adolescent , Adult , Cardiovascular Diseases/epidemiology , Cross-Sectional Studies , Female , Humans , Middle Aged , Obesity , Pregnancy , Pregnant Women , Risk Factors , United States/epidemiology , Young AdultABSTRACT
OBJECTIVES: This study aimed to evaluate the ability of coronary artery calcium (CAC) as an initial diagnostic tool to rule out obstructive coronary artery disease (CAD) in a very large registry of patients presenting to the emergency department (ED) with acute chest pain (CP) who were at low to intermediate risk for acute coronary syndrome (ACS). BACKGROUND: It is not yet well established whether CAC can be used to rule out obstructive CAD in the ED setting. METHODS: We included patients from the Baptist Health South Florida Chest Pain Registry presenting to the ED with CP at low to intermediate risk for ACS (Thrombolysis In Myocardial Infarction risk score ≤2, normal/nondiagnostic electrocardiography, and troponin levels) who underwent CAC and coronary computed tomography angiography (CCTA) procedures for evaluation of ACS. To assess the diagnostic accuracy of CAC testing to diagnose obstructive CAD and identify the need for coronary revascularization during hospitalization, we estimated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV). RESULTS: Our study included 5,192 patients (mean age: 53.5 ± 10.8 years; 46% male; 62% Hispanic). Overall, 2,902 patients (56%) had CAC = 0, of which 135 (4.6%) had CAD (114 [3.9%] nonobstructive and 21 [0.7%] obstructive). Among those with CAC >0, 23% had obstructive CAD. Sensitivity, specificity, PPV, and NPV of CAC testing to diagnose obstructive CAD were 96.2%, 62.4%, 22.4%, and 99.3%, respectively. The NPV for identifying those who needed revascularization was 99.6%. Among patients with CAC = 0, 11 patients (0.4%) underwent revascularization, and the number needed to test with CCTA to detect 1 patient who required revascularization was 264. CONCLUSIONS: In a large population presenting to ED with CP at low to intermediate risk, CAC = 0 was common. CAC = 0 ruled out obstructive CAD and revascularization in more than 99% of the patients, and <5% with CAC = 0 had any CAD. Integrating CAC testing very early in CP evaluation may be effective in appropriate triage of patients by identifying individuals who can safely defer additional testing and more invasive procedures.
Subject(s)
Calcium , Coronary Artery Disease , Adult , Chest Pain/diagnostic imaging , Chest Pain/etiology , Coronary Angiography/methods , Coronary Artery Disease/complications , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/epidemiology , Female , Humans , Male , Middle Aged , Predictive Value of TestsABSTRACT
Disparities in cardiovascular outcomes are persistent in our society. The objective was to track the trends before and after the passage of the Affordable Care Act in socioeconomic status (SES) disparities in utilization of cardiovascular disease (CVD) preventive services among nonelderly adults aged 18-64 years. This study used the National Health Interview Survey (2011-2017) to compare utilization of blood pressure, cholesterol, glycemic screening, and diet and smoking cessation advice over time between groups stratified by SES and race using difference-in-difference analysis. This study also measured the differences over time in specific vulnerable population subgroups (Hispanic, low-income and uninsured vs. White, middle-high-income, and insured). The study population included 176,961 surveyed individuals (mean age 40 [±13] years; 51% female; 67.7% non-Hispanic White) between 2011 and 2017, translating to 194.8 million nonelderly US adults per year. Most individuals were from high-income SES (40.0%), followed by middle-income (28.1%), low-income (13.6%), and lowest income SES (18.3%). The proportion of CVD preventive services increased over all SES categories through the study period. The biggest relative changes were seen among low-income individuals. The difference in blood pressure checks, cholesterol checks, and smoking cessation advise between high- and lowest income groups showed a statistically significant decrease at 5.2%, 4.8%, and 11.2%, respectively, between 2011 and 2017. The findings demonstrate a trend in reduction of CVD preventive care disparities between SES groups. However, a gap still exists, and this study highlights the need for continuous improvement to eliminate SES disparities.
Subject(s)
Cardiovascular Diseases , Patient Protection and Affordable Care Act , Adult , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/prevention & control , Cholesterol , Female , Hispanic or Latino , Humans , Male , Social Class , Socioeconomic Factors , United States/epidemiologyABSTRACT
BACKGROUND: There is little consensus on whether absence of coronary artery calcium (CAC) can identify patients with chest pain (CP) who can safely avoid additional downstream testing. OBJECTIVES: The purpose of this study was to conduct a systematic review and meta-analysis investigating the utility of CAC assessment for ruling out obstructive coronary artery disease (CAD) among patients with stable and acute CP, at low-to-intermediate risk of obstructive CAD undergoing coronary computed tomography angiography (CTA). METHODS: The authors searched online databases for studies published between 2005 and 2021 examining the relationship between CAC and obstructive CAD (≥50% coronary luminal narrowing) on coronary CTA among patients with stable and acute CP. RESULTS: In this review, the authors included 19 papers comprising 79,903 patients with stable CP and 13 papers including 12,376 patients with acute CP undergoing simultaneous CAC and coronary CTA assessment. Overall, 45% (95% CI: 40%-50%) of patients with stable CP and 58% (95% CI: 50%-66%) of patients with acute CP had CAC = 0. The negative predictive values for CAC = 0 ruling out obstructive CAD were 97% (95% CI: 96%-98%) and 98% (95% CI: 96%-99%) among patients with stable and acute CP, respectively. Additionally, the prevalence of nonobstructive CAD among those with CAC = 0 was 13% (95% CI: 10%-16%) among those with stable CP and 9% (95% CI: 5%-13%) among those with acute CP. A CAC score of zero predicted a low incidence of major adverse cardiac events among patients with stable CP (0.5% annual event rate) and acute CP (0.8% overall event rate). CONCLUSIONS: Among over 92,000 patients with stable or acute CP, the absence of CAC was associated with a very low prevalence of obstructive CAD, a low prevalence of nonobstructive CAD, and a low annualized risk of major adverse cardiac events. These findings support the role of CAC = 0 in a value-based health care delivery model as a "gatekeeper" for more advanced imaging among patients presenting with CP.