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Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

Introduction: Assessment of the fatty acid status [particularly the highly labile, long-chain omega-3 species eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)] of both blood and breast milk is important in epidemiological studies that seek to discover relationships between fatty acid status and health outcomes. Both blood and milk samples are difficult to collect and process in the field, and they are expensive to ship frozen to the laboratory. Hence improved approaches to sample acquisition and transport are needed to expand the research base for these metrics. Methods: The purpose of this study was to validate methods to collect, preserve and analyze the fatty acid composition of dried blood spots (DBS) and dried milk spots (DMS). Single drops of blood from 5 volunteers and of milk from 5 lactating women were applied to Whatman 903 cards which had been pretreated with an antioxidant preservative cocktail (OxyStop®). The omega-3 fatty acid content of the milk and the blood samples spanned a 5-fold range. These cards were then kept in the dark at room temperature, 4°C, -20°C, and -80°C for 28 days. Samples were analyzed weekly (in triplicate) and were compared to baseline values and to liquid samples stored under the same conditions. Red blood cells (RBC) from the 5 blood samples were also included in the experiment. Samples were considered stable up until the week that the mean omega-3 fatty acid content had decreased by >10% from baseline. In a separate experiment, the RBC omega-3 index was estimated from the DBS EPA+DHA value using blood samples from 106 healthy subjects. Results: Based on the stability criterion, both DBS and DMS samples were stable for 4 weeks under all storage conditions. RBC EPA+DHA (the omega-3 index) was also stable for 4 weeks under all conditions except storage at -20°C at which temperature degradation occurred within 1 week. The correlation between the omega-3 index and DBS EPA+DHA was 0.98 (p<0.0001) indicating that the RBC omega-3 levels can be accurately estimated from whole blood analysis. DHA levels in liquid vs. dried milk were also strongly correlated (r>0.99; p<0.0001). Conclusion: Both blood and milk omega-3 fatty acid content can be accurately assessed from samples collected and transported at room temperature on filter paper. [ABSTRACT FROM AUTHOR]

Although the number of cardiovascular deaths associated with environmental tobacco smoke cannot be predicted with absolute certainty, the available evidence indicates that environmental tobacco smoke increases the risk of heart disease. The effects of environmental tobacco smoke on cardiovascular function, platelet function, neutrophil function, and plaque formation are the probable mechanisms leading to heart disease. The risk of death due to heart disease is increased by about 30% among those exposed to environmental tobacco smoke at home and could be much higher in those exposed at the workplace, where higher levels of environmental tobacco smoke may be present. Even though considerable uncertainty is a part of any analysis on the health affects of environmental tobacco smoke because of the difficulty of conducting long-term studies and selecting sample populations, an estimated 35,000-40,000 cardiovascular disease-related deaths and 3,000-5,000 lung cancer deaths due to environmental tobacco smoke exposure have been predicted to occur each year. The AHA's Council on Cardiopulmonary and Critical Care has concluded that environmental tobacco smoke is a major preventable cause of cardiovascular disease and death. The council strongly supports efforts to eliminate all exposure of nonsmokers to environmental tobacco smoke. This requires that environmental tobacco smoke be treated as an environmental toxin, and ways to protect workers and the public from this health hazard should be developed. According to a 1989 Gallup survey commissioned by the American Lung Association, 86% of nonsmokers think that environmental tobacco smoke is harmful and 77% believe that smokers should abstain in the presence of nonsmokers.(ABSTRACT TRUNCATED AT 250 WORDS)

Introduction: An standardized definition of myocardial infarction with non-obstructive coronary arteries has recently been published by the European Society of Cardiology. The aim of this study is to analyse clinical profile and prognosis of these patients during a twelve-month follow up Methods: Analytical and observational study developed in a University Hospital, which is the only hospital in an area of 220.000 individuals. We analysed data of all consecutive MINOCA patients (pts) admitted during a three-years period, a total of 118 pts. We compared them with 269 consecutive pts admitted for myocardial infarction with obstructive lesions. We used the definitions and clinical management of 2016 ESC Working Group position paper on MINOCA. We used Chi-square test or Fisher's exact to compare categorical variables. The predicting analysis was made with Kaplan-Meier and Cox regression. Results: A 11.6% of pts with myocardial infarction during that period where MINOCA pts. They were younger (61.8±15.7 vs 67.1±12.9 years, p<0.01) and more frequently women (50.8 vs 22.3% p<0.01) than the obstructive group. MINOCA group also had a better cardiovascular risk profile than the pts with obstructive coronary lesions: hypertension (56.8 vs 62.2%, p 0.37), dyslipidemia (41.9 vs 56.9%, p 0.08), diabetes (18.6 vs 36.6%, p<0.01) and tobacco (45.2 vs 65.1%). MINOCA pts had more frequently a previous history of psychiatric illnesses (29.1 vs 12.6%, p<0.01), and more inflammatory conditions: autoimmune disorders (19.5 vs 10.0%, p 0.014), cancer (10.2 vs 3.7%, p<0.01) and connective tissue diseases (7.6% vs 1.5%, p<0.01).At twelve months follow, MINOCA pts showed less all-cause mortality (8 vs 26%, p<0.01) and cardiovascular mortality (5 vs 20% p<0.01), as well as less rate of MACE (11 vs 17%, p 0.02). However, once adjusted by age and cardiovascular risk factors with Cox regression, being MINOCA has no impact on the prognosis. Conclusions: According to this study, MINOCA has an important prevalence and a special profile, with less traditional risk factors, more proinflammatory conditions and more psychiatric illnesses. This study shows that MINOCA pts have less mortality and rate of MACE during the follow up, although after a multivariable adjust the prognosis was similar to the obstructive group. [ABSTRACT FROM AUTHOR]

Guidelines help to facilitate treatment decisions based on available evidence, and also to provide recommendations in areas of uncertainty. In this paper, we compare the recommendations for stroke workup and secondary prevention of ischemic stroke and transient ischemic attack of the American Heart Association (AHA)/American Stroke Association (ASA) with the European Stroke Organization (ESO) guidelines. The primary aim of this paper is to offer clinicians guidance by identifying areas where there is consensus and where consensus is lacking, in the absence or presence of high-level evidence. We compared AHA/ASA with the ESO guideline recommendations for 7 different topics related to diagnostic stroke workup and secondary prevention. We categorized the recommendations based on class and level of evidence to determine whether there were relevant differences in the ratings of evidence that the guidelines used for its recommendations. Finally, we summarized major topics of agreement and disagreement, while also prominent knowledge gaps were identified. In total, we found 63 ESO and 82 AHA/ASA recommendations, of which 38 were on the same subject. Most recommendations are largely similar, but not all are based on high-level evidence. For many recommendations, AHA/ASA and ESO assigned different levels of evidence. For the 10 recommendations with Level A evidence (high quality) in AHA/ASA, ESO only labeled 4 of these as high quality. There are many remaining issues with either no or insufficient evidence, and some topics that are not covered by both guidelines. Most ESO and AHA/ASA Guideline recommendations for stroke workup and secondary prevention were similar. However not all were based on high-level evidence and the appointed level of evidence often differed. Clinicians should not blindly follow all guideline recommendations; the accompanying level of evidence informs which recommendations are based on robust evidence. Topics with lower levels of evidence, or those with recommendations that disagree or are missing, may be an incentive for further clinical research. [ABSTRACT FROM AUTHOR]

Background: Sinking prebeta lipoprotein is a putative marker for elevated levels of lipoprotein (a). Although prospective data suggest that increased plasma lipoprotein (a) is an independent risk factor for coronary heart disease in men, no prospective studies are available in women., Methods and Results: From 1968 through 1975, sinking prebeta lipoprotein was determined by paper electrophoresis in 3103 women Framingham Heart Study participants who were free of prevalent cardiovascular disease. A sinking prebeta lipoprotein band was detectable in 434 of the women (14%) studied. The median follow-up interval was approximately 12 years. Incident cardiovascular disease was associated with band presence using a proportional hazards model that included age, smoking, body mass index, systolic blood pressure, glucose intolerance, low- and high-density lipoprotein cholesterol, and ECG left ventricular hypertrophy. Multivariable adjusted relative risk estimates (with 95% confidence intervals) for outcomes in the band present versus absent groups were as follows: myocardial infarction (82 events), 2.37 (1.48 to 3.81); intermittent claudication (62 events), 1.94 (1.07 to 3.50); cerebrovascular disease (83 events), 1.88 (1.12 to 3.15); total coronary heart disease (174 events), 1.61 (1.13 to 2.29); and total cardiovascular disease (305 events), 1.44 (1.09 to 1.91). A subset analysis indicated that band presence was 50.9% sensitive and 95.4% specific for detecting plasma lipoprotein (a) levels of > 30 mg/dL, the threshold value linked to increased cardiovascular disease risk in men., Conclusions: Sinking prebeta lipoprotein was a valid surrogate for elevated lipoprotein (a) levels in Framingham Heart Study women. Band presence and, equivalently, elevated plasma lipoprotein (a), was a strong, independent predictor of myocardial infarction, intermittent claudication, and cerebrovascular disease. Confirmation of these findings in other longitudinal studies of women is needed.

The article discusses the use of antiplatelet therapy after percutaneous coronary intervention (PCI) to prevent stent thrombosis and other atherothrombotic events while minimizing bleeding complications. The default strategy of 12 months of dual antiplatelet therapy (DAPT) after PCI has been challenged due to improvements in PCI techniques, stent designs, and antiplatelet pharmacology. The article presents three papers that provide insights into strategies for de-escalation of antiplatelet intensity. The findings suggest that discontinuing aspirin from a ticagrelor-based DAPT regimen and using ticagrelor monotherapy can reduce bleeding risk without affecting the rate of adverse cardiac events. However, the decision to de-escalate antiplatelet therapy should be individualized based on factors such as stent deployment and the presence of high bleeding risk. [Extracted from the article]

The article explores the role of malic enzyme 1 (ME1) in the development of pulmonary hypertension (PH), a serious condition characterized by increased pressure in the arteries of the lungs. The study found that ME1 was more active in the blood vessels of PH patients and animal models. Inhibiting ME1 improved the function of the blood vessels and reduced PH in mice. This suggests that targeting ME1 could be a potential treatment for PH. The article also references three scientific papers that discuss the use of adenosine receptors in treating pulmonary arterial hypertension and cardiovascular health, providing valuable insights for researchers and medical professionals. [Extracted from the article]

Reports highlighting the problems with the standard practice of using bar graphs to show continuous data have prompted many journals to adopt new visualization policies. These policies encourage authors to avoid bar graphs and use graphics that show the data distribution; however, they provide little guidance on how to effectively display data. We conducted a systematic review of studies published in top peripheral vascular disease journals to determine what types of figures are used, and to assess the prevalence of suboptimal data visualization practices. Among papers with data figures, 47.7% of papers used bar graphs to present continuous data. This primer provides a detailed overview of strategies for addressing this issue by (1) outlining strategies for selecting the correct type of figure depending on the study design, sample size, and the type of variable; (2) examining techniques for making effective dot plots, box plots, and violin plots; and (3) illustrating how to avoid sending mixed messages by aligning the figure structure with the study design and statistical analysis. We also present solutions to other common problems identified in the systematic review. Resources include a list of free tools and templates that authors can use to create more informative figures and an online simulator that illustrates why summary statistics are meaningful only when there are enough data to summarize. Last, we consider steps that investigators can take to improve figures in the scientific literature. [ABSTRACT FROM AUTHOR]