Temporal trends and racial/ethnic- and sex-differences in LDL cholesterol control among US adults with self-reported atherosclerotic cardiovascular disease.

Objective: Current guidelines for secondary prevention of atherosclerotic cardiovascular disease (ASCVD) recommend targeting a low-density lipoprotein cholesterol (LDL-C) of < 70 mg/dL. However, temporal trends and racial/ethnic- and sex-differences in achievement of LDL-C targets are not well described. We assessed trends and racial/ethnic- and sex-differences in achievement of LDL-C < 70 mg/dL using data from the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2008 to 2017-March 2020. Methods: We combined NHANES cycles into 4 periods: 2005-2008, 2009-2012, 2013-2016, and 2017-March 2020 and included participants ≥ 40 years with self-reported ASCVD. We estimated LDL-C < 70 mg/dL prevalence over time and further stratified by sex and race/ethnicity. We used multivariable logistic regression adjusted for social determinants of health and clinical covariates to model LDL-C target attainment. Results: Among 1,826 NHANES participants representing 7,161,221 US adults with self-reported ASCVD (59.6% ≥ 65 years, 56.4% male, 74.8% White), LDL-C target attainment increased from 19.0% (95% CI, 15.3%-23.3%) in 2005-2008 to 26.3% (95% CI, 20.4%-33.1%) in 2017-March 2020 (P = 0.012 for trend). Achievement of LDL-C < 70 mg/dL significantly rose among men from19.5% (95% CI, 15.1%-24.8%) to 29.4% (95% CI, 20.7%-29.9%) without significant change in women (from 18.3% [95% CI, 13.6%-24.2%] to 22.5% [95% CI, 13.0%-35.9%]; P = 0.241 for trend). Improvement in LDL-C target attainment was similar among White, Black, and Hispanic individuals (∼5-7% increase) and was greatest among individuals of other (non-White, Hispanic, or Black) race/ethnicity (23.1% increase). In our multivariable analysis, comorbid diabetes and ages 65-75 and > 75 years were associated with LDL-C target attainment. Conclusion: LDL-C control modestly improved between 2005 and 2008 and 2017-March 2020; however, only ∼1/4 of individuals met guideline-directed LDL-C treatment targets by 2017-March 2020. Women had lower LDL-C control and lesser magnitude of improvement in LDL-C control than men, highlighting a need for targeted interventions to improve lipid-lowering therapy utilization in this population.

The Global Epidemic of Metabolic Fatty Liver Disease.

PURPOSE OF REVIEW: The objective of this manuscript is to examine the current literature on the epidemiology of metabolic dysfunction-associated steatotic liver disease (MASLD), its correlation with cardiovascular disease (CVD) outcomes, as well as to evaluate the update in nomenclature from non-alcoholic liver disease (NAFLD). RECENT FINDINGS: The update of diagnostic criteria from NAFLD to MASLD reduces the stigma associated with alcohol consumption and poor health choices. It also shines a light on the crucial role of cardiometabolic risk factors in disease pathophysiology. The incidence and prevalence of MASLD are projected to increase significantly in the future as the population burden of cardiometabolic risk factors rises. MASLD is also a potent risk factor for developing CVD that should be tackled by using a multi-disciplinary team with a holistic approach. As the new nomenclature for metabolic liver disease is adopted on a global scale, more research is needed to investigate the applicability of findings from previous trials focusing on NAFLD. It is anticipated that the epidemic of MASLD will continue to increase globally, hence the urgent need for therapeutic approaches to reverse this trend.

Update on obesity, the obesity paradox, and obesity management in heart failure.

Obesity is a major public health challenge worldwide. It is costly, predisposes to many cardiovascular (CV) diseases (CVD), is increasing at an alarming rate, and disproportionately affects people of low-socioeconomic status. It has a myriad of deleterious effects on the body, particularly on the CV system. Obesity is a major risk factor for heart failure (HF) and highly prevalent in this population, particularly in those with HF with preserved ejection fraction (HFpEF), to the extent that an obesity HFpEF phenotype has been proposed in the literature. However, once HF is developed, an obesity paradox exists where those with obesity have better short- and mid-term survival than normal or underweight individuals, despite a greater risk for hospitalizations. It may be argued that excess energy reserve, younger patient population, higher tolerability of HF therapy and better nutritional status may account for at least part of the obesity paradox on survival. Furthermore, body mass index (BMI) may not be an accurate measure of body composition, especially in HF, where there is an excess volume status. BMI also fails to delineate fat-free mass and its components, which is a better predictor of functional capacity and cardiorespiratory fitness (CRF), which particularly is increasingly being recognized as a risk modifier in both healthy individuals and in persons with comorbidities, particularly in HF. Notably, when CRF is accounted for, the obesity paradox disappears, suggesting that improving CRF might represent a therapeutic target with greater importance than changes in body weight in the setting of HF. In this narrative review, we discuss the current trends in obesity, the causal link between obesity and HF, an update on the obesity paradox, and a description of the major flaws of BMI in this population. We also present an overview of the latest in HF therapy, weight loss, CRF, and the application of these therapeutic approaches in patients with HF and concomitant obesity.

Discordant association of nonalcoholic fatty liver disease with lipoprotein(a) and markers of atherogenic dyslipidemia.

Nonalcoholic fatty liver disease (NAFLD) is associated with atherogenic dyslipidemia and an increased risk of cardiovascular events. Previous studies have suggested an inverse relationship between NAFLD severity and lipoprotein(a) [Lp(a)] level, but contemporary data from the U.S. are lacking. Lp(a), lipid profile, apolipoproteins, and nuclear magnetic resonance-based lipoprotein particle concentrations were measured in 151 patients with biopsy-proven NAFLD. Levels were compared between those with nonalcoholic fatty liver (NAFL) on histology and non-alcoholic steatohepatitis (NASH). Median age was 55 [48, 62] years, 67% of patients were women, 83% were White, 43% had NAFL, and 57% had NASH. Triglyceride level was higher and high-density lipoprotein-cholesterol (HDL-C) was lower among those with NASH as compared with NAFL. Circulating apolipoprotein-B (ApoB) and low-density lipoprotein particle concentration (LDL-P) were 9% and 17% higher in the NASH group as compared with NAFL, respectively. Contrastingly, Lp(a) concentration was 50% lower in NASH relative to NAFL group. Hepatocyte ballooning, lobular inflammation, and fibrosis on histology were inversely associated with Lp(a) concentration. NAFLD severity has a discordant association with Lp(a) and other markers of atherogenic dyslipidemia. This relationship may have implications for prognosticating cardiovascular disease risk in patients with NAFLD.

Biomarkers of Hepatic Dysfunction and Cardiovascular Risk.

PURPOSE OF REVIEW: The objective of this manuscript is to examine the current literature on non-alcoholic fatty liver disease (NAFLD) biomarkers and their correlation with cardiovascular disease (CVD) outcomes and cardiovascular risk scores. RECENT FINDINGS: There has been a growing appreciation for an independent link between NAFLD and CVD, culminating in a scientific statement by the American Heart Association in 2022. More recently, studies have begun to identify biomarkers of the three NAFLD phases as potent predictors of cardiovascular risk. Despite the body of evidence supporting a connection between hepatic biomarkers and CVD, more research is certainly needed, as some studies find no significant relationship. If this relationship continues to be robust and readily reproducible, NAFLD and its biomarkers may have an exciting role in the future of cardiovascular risk prediction, possibly as risk-enhancing factors or as components of novel cardiovascular risk prediction models.

Acute encephalomyelitis in a 52-year-old male post messenger ribonucleic acid severe acute respiratory syndrome coronavirus 2 vaccination: a case report.

BACKGROUND: Acute disseminated encephalomyelitis is a well-known, but rare, side effect of some vaccines, or symptom following a febrile illness. CASE: A 69-year-old, otherwise healthy Hispanic male presented with acute fever, confusion, and later progressive weakness after receiving the first dose of the mRNA-1273 (Moderna) severe acute respiratory syndrome coronavirus 2 vaccine. Considering the progressive deterioration of the patient, despite being on multiple immunosuppressive agents, a brain biopsy was obtained, which revealed nonspecific meningoencephalitis. CONCLUSION: In this case, we highlight the need for a regulatory framework to assist clinicians and patients with coverage of treatment for acute disseminated encephalomyelitis. The use of intravenous immunoglobulin in conjunction with glucocorticoids seems to be an effective treatment option.

Differences in the Clinical Outcome of Ischemic and Nonischemic Cardiomyopathy in Heart Failure With Concomitant Opioid Use Disorder.

Heart Failure (HF) and Opioid Use Disorder (OUD) independently have significant impact on patients and the United States (US) health system. In the setting of the opioid epidemic, research on the effects of OUD on cardiovascular diseases is rapidly evolving. However, no study exists on differential outcomes of ischemic cardiomyopathy (ICM) and nonischemic cardiomyopathy (NICM) in patients with HF with OUD. We performed a retrospective, observational cohort study using National Inpatient Sample (NIS) 2018-2020 databases. Patients aged 18 years and above with diagnoses of HF with concomitant OUD were included. Patients were further classified into ICM and NICM. Primary outcome of interest was differences in all- cause in-hospital mortality. Secondary outcome was incidence of cardiogenic shock. We identified 99,810 hospitalizations that met inclusion criteria, ICM accounted for 27%. Mean age for ICM was higher compared to NICM (63 years vs 56 years, P < 0.01). Compared to NICM, patients with ICM had higher cardiovascular disease risk factors and comorbidities; type 2 diabetes mellitus (46.3 % vs 30.1%, P < 0.01), atrial fibrillation/flutter (33.5% vs 29.9%, P < 0.01), hyperlipidemia (52.5% vs 28.9%, P < 0.01), and Charlson comorbidity index ≥5 was 46.7% versus 29.7%, P < 0.01. After controlling for covariates and potential confounders, we observed higher odds of all-cause in-hospital mortality in patients with NICM (aOR = 1.36; 95% CI:1.03-1.78, P = 0.02). There was no statistical significant difference in incidence of cardiogenic shock between ICM and NICM (aOR = 0.86;95% CI 0.70-1.07, P = 0.18). In patients with HF with concomitant OUD, we found a 36% increase in odds of all-cause in-hospital mortality in patients with NICM compared to ICM despite being younger in age with less comorbidities. There was no difference in odds of in-hospital cardiogenic shock in this study population. This study contributes to the discussion of OUD and cardiovascular diseases which is rapidly developing and requires further prospective studies.

Trends in incidence and clinical outcome of non-ST elevation myocardial infarction in patients with amyloidosis in the United States, 2010-2020.

Study objective: To assess temporal changes in clinical profile and in-hospital outcome of patients with amyloidosis presenting with non-ST elevation myocardial infarction, NSTEMI. Design/setting: We conducted a retrospective observational study using the National Inpatient Sample (NIS) database from January 1, 2010, to December 31, 2020. Main outcomes: Primary outcome of interest was trend in adjusted in-hospital mortality in patients with amyloidosis presenting with NSTEMI from 2010 to 2020. Our secondary outcomes were trend in rate of coronary revascularization, and trend in duration of hospitalization. Results: We identified 272,896 hospitalizations for amyloidosis. There was a temporal increase in incidence of NSTEMI among patients aged 18-44 years from 15.5 % to 28.0 %, a reverse trend was observed in 45-64 years: 22.1 % to 17.7 %, p = 0.043. There was no statistically significant difference in rate of coronary revascularization from 2010 to 2020; 16.3 % to 14.2 %, p = 0.86. We observed an increased odds of all-cause in-hospital mortality in patients with NSTEMI compared to those without NSTEMI (aOR = 2.2, 95 % CI: 1.9-2.6, p < 0.001) but there was a decrease trend in mortality from 21.5 % to 11.3 %, p = 0.013 for trend. Hospitalization duration was also observed to decreased from 14.1 days to 10.9 days during the study period (p = 0.055 for trend). Conclusion: In patients with amyloidosis presenting with NSTEMI, there was increased incidence of NSTEMI among young adults, a steady trend in coronary revascularization, and a decreasing trend of adjusted all-cause in-hospital mortality and length of hospitalization from 2010 to 2020 in the United States.

Interventions and outcomes of COVID-19 patients in a community hospital-A single center study comparing the first and second waves.

BACKGROUND: We have had 3 coronavirus-related pandemics in the last two decades. Each has brought significant toll and with each case there was no cure. Even as vaccines have been developed for the current strain of the virus thereby increasing the prospects of bringing transmissions in communities to a minimum, lessons from this pandemic should be explored in preparation for future pandemics. Other studies have looked at differences in characteristics of patients and mortality rates between the first two waves. In our study we not only identify the differences in outcomes but also explore differences in hospital specific interventions that were implemented at Jersey City Medical Center, NJ, a community-based hospital. AIM: The aim of this study is to assess the differences between the first two waves of the COVID -19 pandemic in terms of management and outcomes to help identify any key lessons in the handling of future pandemics. We compared the population demographics, interventions and outcomes used during the first two waves of COVID-19 in a community-based hospital. METHODS: This is a retrospective single-center cross-sectional study including Laboratory confirmed COVID-19 patients requiring oxygen supplementation admitted at Jersey City Medical Center during the first wave (April 1 to June 30, 2020) and the second wave between (October 1, 2020, and January 1, 2021). The Chi-squared test was used to assess the relationship between categorical variables and the T- test for continuous variables. A Logistic regression model was built comparing the second to the first wave while accounting for important covariates. RESULTS: There was a combined total of 473 patients from both waves. Patients in the first wave were older (66.17 years vs 60.38 years, p <0.01), had more comorbidities (2.75 vs 2.29, p 0.003), had more severe disease (50% vs 38.78% p of 0.002), had a longer length of stay (14.18 days vs 8.77 days, p <0.001) and were more likely to be intubated (32.49% vs 21.9 4%, p 0.01). In the univariate model, the odds of mortality in the second wave compared to the first wave was 0.63 (CI, 0.41-0.96) and 1.73 (CI, 0.65-4.66) in the fully adjusted model. CONCLUSION: Overall, there was no statistically significant difference in mortality between the two waves. Interventions that were noted to be significantly different between the two waves were, increased likelihood of mechanical intubation in the first wave and increased use of steroids in the second wave compared to the first.

Rare Case of Persistently Depressed T Lymphocyte Subsets After SARS-CoV-2 Infection.

BACKGROUND On rare occasions, viral infections are known to also depress immune cell lines, further worsening clinical outcomes. We describe a patient who presented 3 weeks after recovery from mild COVID-19 disease with clinical features of an atypical pneumonia and was found to have a low CD4+ T-cell count. CASE REPORT An 82-year-old man with a past medical history of coronary artery disease, rheumatoid arthritis, gout, hypertension, and atrial fibrillation presented with a 1-week history of progressively worsening shortness of breath and cough. He was noted to have recovered from mild SARS-CoV-2 infection 3 weeks prior to his current presentation and had been at his baseline level of health following infection. A T cell subset panel was obtained, which revealed an absolute CD3 count of 92 (reference range 840-3060), absolute CD4 count of 52 (reference range 500-1400), absolute CD8 count of 37 (reference range 180-1170), and a normal CD4: CD8 ratio. He was subsequently started on atovaquone for pneumocystis jiroveci pneumonia prophylaxis. CONCLUSIONS This case highlights the need for a high index of suspicion for lymphocyte depletion in older patients with multiple comorbidities who present during or after SARS-CoV-2 infection with atypical symptoms that are suggestive of immunosuppression. In such instances, there should be a low threshold to start prophylactic therapy for possible opportunistic infections.

Allostatic Load in Perimenopausal Women With Migraine.

Objective: There is very limited data on women with migraine disease as they age and transition to menopause. Despite evidence for the increased burden of the disease during this transition, there is no data on the association between migraine and allostatic load as a marker of cumulative biological risk. We aimed to determine whether women with migraine suffer from higher levels of allostatic load during perimenopausal transition. Methods: A total of 2,105 perimenopausal women from the first wave of the Study of Women's Health Across the Nation (SWAN) were included in this study. Allostatic Load (AL) score was estimated for each participant from the measurements of: systolic and diastolic blood pressure, C-reactive protein level, high-density lipoprotein cholesterol level, total cholesterol level, waist-to-hip ratio, fasting serum glucose, triglycerides, and dehydroepiandrosterone levels. Results: Of the 2,105 participants included in the study, there were 369 migraineurs and 1,730 controls. Migraineurs had 63% higher odds of increased load score (odds ratio 1.63; 95% confidence interval, 1.17-2.29). Compared to controls, migraineurs were more likely to experience sleep problems in the univariate analysis, however despite the high burden of sleep problems, there were no significant associations between allostatic load and sleep disturbances in perimenopausal women with migraine after controlling for other factors. Conclusion: This is the first study to systematically and quantitatively examine allostatic load in migraine patients. The findings establish that migraineurs are more likely to experience higher allostatic load than their non-migraine counterparts during perimenopausal transition. The findings encourage new lines of investigation for lowering the burden of the disease through interventions that modify the levels of allostatic load biomarkers examined in this study.