Impact of weather and pollution on the rate of cerebrovascular events in a large metropolitan area.

BACKGROUND: Despite mounting evidence, there is uncertainty on the impact of the interplay between weather and pollution features on the risk of acute cerebrovascular events (CVE). We aimed at appraising role of weather and pollution on the daily risk of CVE. METHODS: Anonymized data from a hub CVE center in a large metropolitan area were collected and analyzed according to weather (temperature, pressure, humidity, and rainfall) and pollution (carbon monoxide [CO], nitrogen dioxide [NO2], nitrogen oxides [NOX], ozone [O3], and particulate matter [PM]) on the same and the preceding days. Poisson regression and time series analyses were used to appraise the association between environmental features and daily CVE, distinguishing also several subtypes of events. RESULTS: We included a total of 2534 days, with 1363 days having ≥1 CVE, from 2012 to 2017. Average daily rate was 1.56 (95% confidence interval: 1.49; 1.63) for CVE, with other event rates ranging between 1.42 for stroke and 0.01 for ruptured intracranial aneurysm. Significant associations were found between CVE and temperature, pressure, CO, NO2, NOX, O3, and PM <10 µm (all P<0.05), whereas less stringent associations were found for humidity, rainfall, and PM <2.5 µm. Time series analysis exploring lag suggested that associations were stronger at same-day analysis (lag 0), but even environmental features predating several days or weeks were significantly associated with events. Multivariable analysis suggested that CO (point estimate 1.362 [1.011; 1.836], P=0.042) and NO2 (1.011 [1.005; 1.016], P<0.001) were the strongest independent predictors of CVE. CONCLUSIONS: Environmental features are significantly associated with CVE, even several days before the actual event. Levels of CO and NO2 can be potentially leveraged for population-level interventions to reduce the burden of CVE.

Impact of arterial hypertension and its management strategies on cognitive function and dementia: a comprehensive umbrella review.

INTRODUCTION: Cognitive decline and dementia recognize multiple risk factors and pathophysiological mechanisms, often involved simultaneously with complex interactions. Several studies have shown that both arterial hypertension and hypotension are associated with a greater risk of cognitive decline and dementia, but clinical evidence on this point is conflicting. Our aim was to conduct an umbrella review on cognitive function, dementia, and blood pressure, with particular attention to epidemiological, prognostic and therapeutic aspects. EVIDENCE ACQUISITION: We conducted a dedicated literature search on PubMed for systematic reviews and meta-analyses that focused on arterial pressure, hypertension, hypotension and similar conditions, and cognitive function, cognitive decline and dementia. The internal validity of systematic reviews and meta-analyses was formally analyzed using the OQAQ tool. The umbrella review was planned in accordance with current international recommendations and was described as specified by the PRISMA guidelines. EVIDENCE SYNTHESIS: Seventeen systematic reviews (including 13 meta-analyses) were included, for a total of 675 clinical studies and over 1 million patients. Hypertension results to be associated with a lower risk of Alzheimer's dementia, greater risk of vascular dementia and greater risk of cognitive decline. Orthostatic hypotension seems to be associated with greater risk of Alzheimer's dementia, vascular dementia and dementia of Parkinson's disease. Therapy with acetylcholinesterase inhibitors produces lower risk of cardiovascular events, greater risk of hypertension and greater risk of bradycardia, while the anti-hypertensive therapy leads to a lower risk of dementia of all types and lower risk of cognitive decline. CONCLUSIONS: To date, the evidence on the relationship between blood pressure, cognitive decline and dementia provides somewhat heterogeneous data. Further studies are clearly needed, with explicit inclusion criteria as objective as possible, adequate follow-up and precise characterization of implemented cardiovascular and cognitive treatments.

What about heart and mind in the COVID-19 era?

From the time of Hippocratic medicine, heart-brain interactions have been recognized and contributed to both mental and physical health. Heart-brain interactions are complex and multifaceted and appear to be bidirectional. Exposure to chronic and daily stressors such as quarantine, or severe psychological trauma like a significant person in danger of life can affect the cardiovascular system and the emotional experience of the individual, leading to an increased risk of developing a cardiovascular disease or mental illness. Subjects with comorbidities between mental disorders and heart diseases are obviously more susceptible to be influenced by emotional burden due to the spread of COVID-19, with emotional responses characterized by fear, panic, anger, frustration. Psychological services and crisis interventions are needed at an early stage to reduce anxiety, depression and post-traumatic stress disorder in such a stressful period, with a special attention to special groups of patients, such as women, children, or the elderly.

Oral antiplatelet therapy in the elderly undergoing percutaneous coronary intervention: an umbrella review.

Percutaneous coronary intervention has become a mainstay in the management of coronary artery disease. While initially advanced age was considered a relative contraindication to invasive management of coronary artery disease, current cardiovascular practice stands solidly on an early invasive approach for elderly patients, typically based on radial access and drug-eluting stent implantation. Since the advent of coronary stents, oral antiplatelet therapy has proved crucial to maximize the benefits and minimize the risks of stenting, and this holds even truer in older patients rather than in younger ones. Indeed, the elderly is typically at higher risk of thrombotic events as well as bleeding complications, and thus careful decision making must be exercised to prescribe the most appropriate antiplatelet regimen. We thus conducted an umbrella review with scoping purposes on oral antiplatelet therapy in elderly patients undergoing percutaneous coronary intervention, retrieving 8 pertinent systematic reviews. We found that, while several drugs are available, ranging from aspirin to cilostazol, clopidogrel, dipyridamole, prasugrel, ticagrelor, and ticlopidine, most commonly a dual antiplatelet therapy comprising aspirin and a P2Y12 inhibitor is recommended, with subtle adjustments for pretreatment, loading, dose, duration, escalation or de-escalation, with the potential adjunct in selected patients of novel oral anticoagulants. Indeed, a flexible and individualized approach to oral antiplatelet therapy in elderly patients undergoing percutaneous coronary intervention is paramount, factoring patient features (exploiting thrombotic, bleeding and frailty scores), triage (including when appropriate non-invasive assessment of anatomic and functional significance of coronary artery disease), angiographic and other invasive imaging features, interventional technique, stent choice, rehabilitation, and secondary prevention.

Correction to: Atherothrombosis Prevention and Treatment with Anti-interleukin-1 Agents.

The original version of this article unfortunately contained typo in the 2nd author's family name. Instead of "Garmenda", it should be "Garmendia". The original version has been corrected.

Atherothrombosis Prevention and Treatment with Anti-interleukin-1 Agents.

PURPOSE OF REVIEW: Despite major advances in terms of prevention, diagnosis, risk-stratification, management and rehabilitation, atherosclerosis and atherothrombosis continue to have major morbidity and mortality implications worldwide. Since the unraveling of the pivotal role of inflammation in atherothrombosis pathophysiology, several focused treatments have been proposed with the ultimate goal of preventing or treating myocardial infarction, stroke, and peripheral artery disease. In particular, given the centrality of interleukin-1 (IL-1), targeted anti-IL-1 agents have attracted substantial attention and efforts. Yet, uncertainty persists on the real risk-benefit and cost-benefit balance of anti-IL-1 agents in patients with or at risk of atherothrombosis. RECENT FINDINGS: Several trials have been recently completed on atherothrombosis prevention and treatment with anti-IL-1 agents, ranging, for instance, from the large Canakinumab Antiinflammatory Thrombosis Outcome Study (CANTOS) trial to the series of translational studies conducted within the Virginia Commonwealth University-Anakinra Remodeling Trial (VCU-ART) platform. In light of the present scoping umbrella review, it appears evident that anti-IL-1 agents can reduce systemic inflammation and improve surrogate markers of cardiac and vascular function, with potential benefits on the risk of new/worsening heart failure. One trial suggested an increased risk of major adverse events with anti-interleukin-1 agents, possibly due to a rebound phenomenon, but this was based on a post-hoc analysis of a small number of events, and it was not supported by all other pertinent trials. The CANTOS study showed a potential hazard due to an increased risk of fatal infections, but the effect size was rather small. In addition, cost issues limit the foreseeable scope of these treatment strategies in unselected patients, calling instead for more refined prescribing. The evidence base on the risk-benefit and cost-benefit profile of anti-IL-1 agents for atherothrombosis prevention and treatment has expanded substantially in the last decade. While largely dominated by the landmark CANTOS trial, effect estimates also including the VCU-ART trials suggest complex short- and long-term effects which may prove favorable in carefully selected patients with acute or chronically sustained inflammation. Conversely, more liberal use appears less promising, and further studies with currently available agents or novel ones are eagerly needed to better define their role in the era of precision molecular medicine.

Sleep quality in patients with primary Sjögren's syndrome.

OBJECTIVES: To assess the sleep quality in primary Sjögren's syndrome (pSS) patients and evaluate its relationship with the disease, quality of life and mood disorders. METHODS: The sleep quality of 29 pSS women and 29 matched controls was assessed by the Pittsburgh Sleep Quality Index (PSQI). Seven domains are grouped according to three factors: F1 perceived sleep quality (subjective sleep quality, sleep latency, use of sleeping medication), F2 sleep efficiency (sleep duration, habitual sleep efficiency) and F3 daily disturbances (sleep disturbances, daytime dysfunction). These domains are scored as a single factor of global sleep quality. The Short Form Health Survey (SF-36), Functional Assessment of Chronic Illness Therapy (FACIT) fatigue scale and Hospital Anxiety and Depression Scale (HADS) were also administered. Disease activity and damage were evaluated with the EULAR Sjögren's syndrome disease activity index (ESSDAI), the Sjögren's Syndrome Disease Activity and Damage Indexes (SSDAI, SSDDI). RESULTS: The mean PSQI global score had higher pathological values (8.6±4.6) compared with controls (5.6±2.2) (p=0.002). F1 and F3 were significantly worse in cases (p=0.01, p=0.009). A negative correlation was found between SF-36 subscales and the global PSQI, F2 and F3. The anxiety HADS correlated with F2 and F3, while depression only with F3. No correlation with FACIT and disease indexes emerged. CONCLUSIONS: Using PSQI, an impaired sleep quality was demonstrated in pSS patients, especially with perceived quality and the daily disturbances. It is associated with a reduced quality of life but not with disease-related variables.

Quality of Sexual Life in Women with Primary Sjögren Syndrome.

OBJECTIVE: To assess the quality of sexual life of women with primary Sjögren syndrome (pSS) and to identify its correlations with disease activity and damage, quality of life, and mood disorders. METHODS: The quality of sexual life of 24 women with pSS was assessed with the Female Sexual Function Index (FSFI). Twenty-four healthy women, matched by age and hormonal status, were enrolled as controls. Mood disorders and quality of life were investigated using the Hospital Anxiety and Depression Scale (HADS) and the Medical Outcomes Study Short Form-36. Patients underwent a gynecological visit with vaginal pH measurement, cervicovaginal swabs, and Pap smears. Disease activity and damage were assessed by the European League Against Rheumatism Sjögren syndrome disease activity and damage indexes. RESULTS: Patients with pSS showed a pathological mean FSFI score (19.1 ± 7.33) significantly different from controls (p = 0.004), both in menstruating women (p = 0.006) and in menopausal women (p = 0.03). Major differences between the 2 groups were detected in dyspareunia (p < 0.005), lubrication (p = 0.006), desire (p = 0.004), and arousal (p = 0.018). The FSFI score was inversely correlated with age (p = 0.008) and anxiety HADS (p = 0.031). No early anatomical changes, swabs, and Pap smear alterations were revealed in patients with pSS; however, vaginal pH was higher than normal in premenopausal patients (6.0 ± 0.77). CONCLUSION: Both premenopausal and postmenopausal women with pSS have a worse sexual quality of life. We reported a greater prevalence of dyspareunia that is statistically significant when compared with controls. The FSFI could be a useful tool to assess this topic, but has been neglected in the care of patients with pSS heretofore.