Pantoprazole to Prevent Gastroduodenal Events in Patients Receiving Rivaroxaban and/or Aspirin in a Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND & AIMS: Antiplatelets and anticoagulants are associated with increased upper gastrointestinal bleeding. We evaluated whether proton pump inhibitor therapy could reduce this risk. METHODS: We performed a 3 × 2 partial factorial double-blind trial of 17,598 participants with stable cardiovascular disease and peripheral artery disease. Participants were randomly assigned to groups given pantoprazole 40 mg daily or placebo, as well as rivaroxaban 2.5 mg twice daily with aspirin 100 mg once daily, rivaroxaban 5 mg twice daily, or aspirin 100 mg alone. The primary outcome was time to first upper gastrointestinal event, defined as a composite of overt bleeding, upper gastrointestinal bleeding from a gastroduodenal lesion or of unknown origin, occult bleeding, symptomatic gastroduodenal ulcer or ≥5 erosions, upper gastrointestinal obstruction, or perforation. RESULTS: There was no significant difference in upper gastrointestinal events between the pantoprazole group (102 of 8791 events) and the placebo group (116 of 8807 events) (hazard ratio, 0.88; 95% confidence interval [CI], 0.67-1.15). Pantoprazole significantly reduced bleeding of gastroduodenal lesions (hazard ratio, 0.52; 95% confidence interval, 0.28-0.94; P = .03); this reduction was greater when we used a post-hoc definition of bleeding gastroduodenal lesion (hazard ratio, 0.45; 95% confidence interval, 0.27-0.74), although the number needed to treat still was high (n = 982; 95% confidence interval, 609-2528). CONCLUSIONS: In a randomized placebo-controlled trial, we found that routine use of proton pump inhibitors in patients receiving low-dose anticoagulation and/or aspirin for stable cardiovascular disease does not reduce upper gastrointestinal events, but may reduce bleeding from gastroduodenal lesions. ClinicalTrials.gov ID: NCT01776424.

SF-36 predicts 13-year CHD incidence in a middle-aged Swedish general population.

PURPOSE: To study the predictive ability of each of the eight scales of SF-36 on 13-year all-cause mortality and incident coronary heart disease (CHD) in a general middle-aged population. METHODS: The population-based, longitudinal "Life-conditions, Stress and Health" study, in 2003-2004 enrolled 1007 persons aged 45-69 years (50% female), randomly sampled from the general population in Östergötland, Sweden. Variables at baseline included the SF-36 (health-related quality of life, HRQoL) and self-reported disease. Incident CHD (morbidity and mortality) and all-cause mortality data for the study population during the first 13 years from baseline were obtained from national Swedish registries. RESULTS: Seven of the eight SF-36 scales predicted CHD (sex- and age-adjusted Hazard Ratios up to 2.15; p ≤ 0.05), while only the Physical Functioning scale significantly predicted all-cause mortality. Further adjustments for presence of (self-reported) disease did not, in most cases, alter these significant predictions. CONCLUSION: Low SF-36 scores predict risk of CHD, also after adjustment for present disease, supporting the biopsychosocial model of health and disease. Measures of HRQoL yield important information and can add to the cardiopreventive toolbox, including primary prevention efforts, as it is such a simple and relatively inexpensive tool.

Do we have new preventive strategies for optimizing cardiovascular health in women?

Over the past decades, progress in efforts to reduce cardiovascular morbidity and mortality has been achieved, although a disturbing trend for stagnation of cardiovascular mortality rates among younger women compared with those in younger men has been identified. While the menopause transition has traditionally offered an unequivocal opportunity to assess cardiovascular risk and counsel women to adopt preventive strategies, the veritable 'window of opportunity', usually applied to the concept of timing the initiation of menopausal hormone therapy, must be opened much wider to encompass younger women including those who have experienced adverse events during pregnancy, treatment for breast cancer, and premature menopause. Collaborative efforts by a number of expert medical groups provide encouragement and justification for an aggressive approach to identify and modify cardiovascular risk earlier in younger women, starting at age 20 years. Quantifying cardiovascular risk with country and population-specific risk calculators can be helpful to validate perception of risk and encourage preventive recommendations. Adherence to established guidelines for lifestyle measures (smoking cessation, healthful eating habits, enhanced physical activity, and weight control) along with treatment of traditional risk factors - hypertension, glucose intolerance, and dyslipidemia - provides a sound basis for prevention of cardiovascular disease in women.

Cardiovascular Disease Prevention: Training Opportunities, the Challenges, and Future Directions.

PURPOSE: Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality worldwide, necessitating major efforts in prevention. This review summarizes the currently available training opportunities in CVD prevention for fellows-in-training (FITs) and residents. We also highlight the challenges and future directions for CVD prevention as a field and propose a structure for an inclusive CVD prevention training program. RECENT FINDINGS: At present, there is a lack of centralized training resources for FITs and residents interested in pursuing a career in CVD prevention. Training in CVD prevention is not an accredited subspecialty fellowship by the American Council of Graduate Medical Education (ACGME). Although there are several independent training programs under the broad umbrella of CVD prevention focusing on different aspects of prevention, there is no unified curriculum or training. More collaborative efforts are needed to identify CVD prevention as an ACGME-accredited subspecialty fellowship. Providing more resources can encourage and produce more leaders in this essential field.

Aspirin dosing frequency in the primary and secondary prevention of cardiovascular events.

Aspirin has been a cornerstone of cardiovascular disease prevention since the late 1980s. Despite the popularity of aspirin and its wide use, the proper dosing and frequency of aspirin has yet to be determined. Early aspirin trials focused on its utility in broad target populations, but this strategy did not magnify the benefit of aspirin, and rather increased the complication rate. We have learned from previous studies that laboratory and clinical response to aspirin therapy in patients with different conditions and settings are diverse. This difference in aspirin response necessitates a personalized, tailored aspirin therapy. We aim to perform a comprehensive review of the current evidence surrounding aspirin responsiveness in several distinct patient populations and the rationale of different aspirin frequency and dosing strategies. Our conclusions call for future studies to determine individualized aspirin strategies to maximize the benefit and minimize the risk of aspirin.

Towards Optimal Cardiovascular Health: A Comprehensive Review of Preventive Strategies.

Heart disease remains a prominent global health concern, with cardiovascular disease (CVD) standing as a leading cause of death worldwide. Preventing heart disease not only decreases the risk of premature death but also mitigates complications like heart attacks, strokes, and arrhythmias, thereby enhancing overall health and quality of life. The economic burden of heart disease treatment highlights the importance of implementing preventive measures, such as lifestyle changes and early interventions, which can alleviate healthcare costs. These strategies, targeting risk factors like hypertension (HTN), diabetes mellitus (DM), dyslipidemia, and obesity, not only prevent heart disease but also reduce the risk of other health issues. Herein, this review covers various preventive measures, including dietary interventions, exercise, controlling HTN, DM, cholesterol, and weight, smoking cessation, and pharmacological interventions. By critically analyzing the guidelines and leveraging robust data alongside variations in recommendations, this review aims to elucidate effective primary prevention strategies for CVD.

Forecasting Atrial Fibrillation: The Predictive Power of N-terminal Prohormone of Brain Natriuretic Peptide in a Five-Year Study.

Introduction Atrial fibrillation (AF) is a major global health concern, and early prediction is essential for managing high-risk individuals. N-terminal prohormone of brain natriuretic peptide (NT-proBNP) has emerged as a crucial biomarker for predicting AF. While most studies have concentrated on cohorts already diagnosed with AF or other cardiac diseases, this research investigates the predictive value of NT-proBNP for AF development in a population without prior AF diagnosis. Methods and materials A five-year prospective observational study was conducted on 4090 individuals aged 45 to 75 with no previous diagnosis of AF. Baseline demographic characteristics, comorbid conditions, cardiac-specific measures, and NT-proBNP levels were systematically recorded. The primary endpoint was the onset of AF, confirmed through annual 12-lead ECG or 24-hour Holter monitoring. Univariate and multivariate analyses identified factors associated with AF onset. Results Out of the total population, 16.6% (679 individuals) developed AF. Notably, increased NT-proBNP levels (P=0.001), older age (P=0.001), and hypertension (P=0.001) were significantly associated with the onset of AF. The mean NT-proBNP levels in the AF group were significantly higher than in the non-AF group (P<0.001). The AF group also showed a higher mean age and a greater prevalence of hypertension (P<0.001 for both). Conclusion This study confirms the predictive value of NT-proBNP for AF onset in a non-AF population, highlighting older age and hypertension as significant risk factors for AF development. The findings underscore the potential of NT-proBNP not only as a predictive biomarker but also as a therapeutic target. These insights emphasize the potential role of NT-proBNP in early intervention and management strategies for AF, suggesting that future research should include additional variables, such as lifestyle factors and genetic predisposition, in assessing AF risk.

Cardiac well-being indexes: a decision support tool to monitor cardiovascular health.

Despite the increasing awareness about its severity and the importance of adopting preventive habits, cardiovascular disease remains the leading cause of death worldwide. Most people already recognize that a healthy lifestyle, which includes a balanced diet and the practice of physical activity, is essential to prevent this disease. However, since few simple mechanisms allow a self-assessment and a continuous monitoring of the level of cardiac well-being, people are not conscious enough about their own cardiovascular health status. In this context, this paper presents and describes a tool related to the creation of cardiac well-being indexes that allow a quick and intuitive monitoring and visualization of the users' cardiovascular health level over time. For its implementation, data mining techniques were used to calculate the indexes, and a data warehouse was built to archive the data and to support the construction of dashboards for presenting the results.

Trends in low-density lipoprotein-cholesterol blood values between 2012 and 2017 suggest sluggish adoption of the recent 2013 treatment guidelines.

BACKGROUND: Over a 14-year period, age-adjusted high total cholesterol (≥240 mg/dL) in the United States declined from 18.3% in 1999 to 2000 to 11.0% in 2013 to 2014, coinciding with the 2001 National Cholesterol Education Program Adult Treatment Panel (ATP)-III guidelines that endorsed low-density lipoprotein (LDL)-cholesterol blood value goals. Statin treatment recommendations were revised by the American College of Cardiology and the American Heart Association (ACC/AHA) in November 2013 to a "risk-based prescription" approach that did not utilize blood cholesterol values. This increased dosage and expanded the statin-eligible population by an estimated 12.8 million US adults. These changes should further lower total and LDL cholesterol concentrations nationally. METHODS: We examined data from 507 752 patients nationally aged ≥16 years whose fasting bloods were sent to Boston Heart Diagnostics for direct LDL-cholesterol measurements. Between 2012 and 2017, age-adjusted concentrations were examined by analysis of covariance and LDL-cholesterol ≥160 mg/dL by logistic regression. RESULTS: Contrary to expectations, age-adjusted mean LDL-cholesterol concentrations (±SE, mg/dL) increased significantly (P < 10-16 ) in men (2012:113.8 ± 0.3; 2013:115.3 ± 0.2; 2014:114.7 ± 0.2; 2015:116.0 ± 0.2; 2016:117.6 ± 0.2; and 2017:117.1 ± 0.2 mg/dL) and women (2012:119.5 ± 0.3; 2013:120.7 ± 0.2; 2014:119.8 ± 0.02; 2015:120.8 ± 0.2; 2016:122.7 ± 0.1; and 2017:123.8 ± 0.2 mg/dL). The percentage with LDL-cholesterol ≥160 mg/dL also increased significantly (P < 10-9 ) in men and women. Similar results were obtained for ages 40 to 75 years olds (corresponding to ACC/AHA guidelines). CONCLUSION: These results provide additional evidence that declining blood LDL-cholesterol levels observed following the ATP-III recommendations, did not further decline (actually increased) following the 2013 ACC/AHA recommendations.

Educational level and risk profile and risk control in patients with coronary heart disease.

BACKGROUND: The purpose of this study was to ascertain way in which conventional risk factors, readiness to modify behaviour and to comply with recommended medication, and the effect of this medication were associated with education in patients with established coronary heart disease (CHD). METHODS: The EUROASPIRE IV (EUROpean Action on Secondary Prevention by Intervention to Reduce Events) study was a cross-sectional survey undertaken in 24 European countries to ascertain how recommendations on secondary CHD prevention are being followed in clinical practice. Consecutive patients, men and women ≤80 years of age who had been hospitalized for an acute coronary syndrome or revascularization procedure, were identified retrospectively. Data were collected through an interview with examinations at least six months and no later than three years after hospitalization. RESULTS: A total of 7937 patients (1934 (24.37%) women) were evaluated. Patients with primary education were older, with a larger proportion of women. Control of risk factors, as defined by Joint European Societies 4 and 5 guidelines, was significantly better with higher education for current smoking (p = 0.001), overweight and obesity (p = 0.047 and p = 0.029, respectively), low physical activity (p < 0.001) and low high-density lipoprotein (HDL)-cholesterol (p = 0.011) in men, and for obesity (p = 0.005), high blood pressure (p < 0.005 and p < 0.001), low physical activity (p = 0.001), diabetes (p < 0.001) and low HDL-cholesterol (p = 0.023) in women. Patients with primary and secondary education were more often treated with diuretics and antidiabetic drugs. Better control of hypertension was achieved in patients with higher education. CONCLUSION: Particular risk communication and control are needed in secondary CHD prevention for patients with lower educational status.

Fish oil in primary and secondary cardiovascular prevention.

Omega-3 fatty acid therapy shows great promise in both primary and secondary prevention of cardiovascular (CV) diseases, especially coronary heart disease (CHD). In this review, we discuss the evidence available from prospective and retrospective observational epidemiologic studies and controlled clinical trials demonstrating the effects of omega-3 fatty acids (fish oil) in primary and especially secondary prevention of major CV events, including CV mortality, fatal and nonfatal myocardial infarction (MI), and sudden cardiac death (SCD). Significant reductions in total mortality and SCD to the extent of 20% to 50% have been found in studies using doses ranging from 0.85 to 4.0 g/d. We review the compelling evidence that indicates all clinicians should strongly consider therapy with fish oil, specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), for patients with known CV disease and for patients at increased risk for CV disease, particularly patients at increased risk for SCD. The target DHA + EPA consumption levels are about 800 to 1000 mg/d for individuals with known CHD and at least 500 mg/d for individuals without disease.

Acute rheumatic fever in Africa.

PIP: Acute rheumatic fever (RF) is a common health problem in Africa, Asia, and South America. This article gives a description of the clinical diagnosis, management, and prevention of RF. The seriousness of the problem is reflected in the fact that almost 13.3% of the population in the developing world may be throat carriers of RF, and almost 40% of infected persons may suffer from the tragic complication, rheumatic heart disease (RHD). Incidence of RHD in Africa is estimated at 17-43% of all cardiovascular disease. RF is the result of complications from group A hemolytic streptococcal infection of the upper respiratory tract. Severity of RF infection is determined by the severity of the streptococcal infection, length of time the organism survived in the throat, degree of antistreptolysin response, early age of onset, and frequent undiagnosed recurrences. RF is prevalent among children aged 5-10 years, and males are more affected. Acute RF occurs within two weeks of acute streptococcal infections. Predisposing factors are identified as low socioeconomic status, poor sanitation, and genetic propensity. The modified Jones criteria is useful in diagnosing RF, either with two major criteria or one major and two minor criteria. Obstacles to early detection of RF are stated as late medical assessment when symptoms are no longer present, little medical history of sore throats, frequent indiscriminate use of antibiotics and salicylates, and mild attacks not included in the Jones criteria. Diagnosis is dependent upon a high index of suspicion and good clinical judgment. Treatment of acute RF involves complete bed rest and administration of 50 mg/kg daily of acetyl salicylate for children unless signs of rheumatic activity reappear. Caution is urged in prescribing large doses. Corticosteroids may be administered in carditis cases. Penicillin may be given in the acute stage, but this does not prevent RHD. Premature administration of drugs may obscure RHD. Diuretics may be used for cardiac failure. Primary prevention involves avoidance of contact with persons with colds and upper respiratory tract infections, prevention of infection, prompt treatment of streptococcal sore throat, improved standards of housing, and possibly immunization. Prevention of reoccurrences may include administration of benzathine penicillin (0.6-1.2 mu monthly) or penicillin V (125-250 mg, twice daily) until the age of 25 years is reached. Serious complications are permanent heart damage and economic costs.^ieng