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Atherosclerosis within 2 or more arterial beds has been termed polyvascular disease. Although polyvascular disease has long been associated with heightened cardiovascular risk, much is still unknown regarding its pathophysiology and management. In this past decade, the field of cardiovascular disease has experienced exponential growth in terms of antithrombotic and lipid-lowering therapies aimed at mitigating ischemic events. This review describes the inherent risk associated with polyvascular disease in contemporary observational and clinical trial populations and summarizes novel therapies in this high-risk population.

OBJECTIVE: Insulin resistance is associated with increased lipolysis and elevated concentrations of free fatty acids, which in turn contribute to impaired vascular function. We hypothesized that lowering free fatty acids with acipimox, a nicotinic acid derivative that impairs free fatty acid efflux, would improve endothelial function, measured by flow-mediated dilation, in individuals with metabolic syndrome. METHODS: Eighteen subjects with metabolic syndrome and 17 healthy controls were enrolled and treated with acipimox 250 mg orally every 6 hours, or placebo, for 7 days in a randomized, double-blind, crossover trial. RESULTS: Acipimox reduced free fatty acid concentrations among individuals with metabolic syndrome to near normal levels (P=0.01), but there was no change among healthy controls (P=0.17). Acipimox did not improve endothelial-dependent flow-mediated dilation in either group (metabolic syndrome: P=0.42, and healthy controls: P=0.16), although endothelial-independent nitroglycerin-mediated dilation among those with metabolic syndrome tended to increase (20.3%, P=0.06). There were no changes in blood lipids or markers of inflammation following therapy. There was minimal correlation between change in flow-mediated dilation and baseline measures of body-mass index (ρ=−.09) or waist circumference (ρ=−0.15). CONCLUSIONS: In groups with normal or elevated baseline free fatty acids, short-term reductions do not improve endothelial function assessed by flow-mediated dilation.

PURPOSE OF REVIEW: This review of the literature aims to discuss the evidence linking different lipid and apolipoprotein measures to peripheral artery disease. RECENT FINDINGS: Measures of atherogenic dyslipidemia, including elevations in total cholesterol and total cholesterol:high-density lipoprotein cholesterol as well as low levels of high-density lipoprotein cholesterol, are strongly associated with future risk of peripheral artery disease. Compared to coronary artery disease, there are fewer data showing an association between low-density lipoprotein cholesterol and future risk of peripheral artery disease. Novel lipid measures, including nuclear magnetic resonance-derived lipoproteins and oxidized lipids, may lead to better assessments of future peripheral artery disease risk. SUMMARY: These data highlight the important differences between lipid risk factors for peripheral and coronary artery disease. Improved understanding of these distinctions may lead to new therapeutic options for patients with peripheral artery disease.

Background: Elevated triglyceride rich lipoproteins (TRLs) and small dense LDL (sdLDL) levels are hallmarks of atherogenic dyslipidemia and the cholesterol content of these particles is hypothesized to drive atherosclerotic risk. However, laboratory quantitation has thus far been impractical with limited prospective clinical data utilizing directly measured levels of this cholesterol burden. Methods: We conducted a prospective case-cohort study within the Women’s Health Study. Randomly selected CVD case subjects (n=500) were compared to a reference subcohort (n=496). TRL-C and sdLDL-C (mg/dl) were directly measured in baseline blood specimens. Cox proportional hazards models were used to compute quartile-specific multivariable-adjusted HRs for total CVD and individual outcomes of coronary and cerebrovascular disease (CCVD) and peripheral artery disease (PAD). Clinical models also adjusted for LDL-C and hsCRP. Results: TRL-C and sdLDL-C were strongly correlated ( ρ =0.716, padj Q4 vs Q1: total events 1.87, 95% CI 1.14 - 3.06, p=0.012; CCVD 1.81, 95% CI 1.05 - 3.09, p = 0.030; PAD 2.43, 95% CI 1.11 - 5.31, p=0.039). In contrast, elevated sdLDL-C associated with incident CCVD but not PAD (HR adj Q4 vs Q1: total events 1.85, 95% CI 1.04 - 3.31, p=0.014; CCVD 2.17, 95% CI 1.14 - 4.13, p = 0.006; PAD 1.34, 95% CI 0.54 - 3.33, p=0.389). Conclusion: Directly measured TRL-C and sdLDL-C concentrations are strongly linked to incident CVD with potentially differential effects for PAD. These findings may indicate a greater potential benefit of therapeutics targeting TRL-C rather than LDL in the prevention of PAD.

Two days after undergoing uncomplicated bilateral total knee arthroplasties, a 72-year-old man had a temperature of 101°F and a pruritic, erythematous rash that originated on his trunk and spread peripherally to his arms and upper thighs over the course of 24 hours.

There are no large national cohorts examining the incidence of peripheral artery disease (PAD) among participants previously tested for PAD by ankle-brachial index (ABI) at baseline. Such data are critical as prevalent PAD often goes unrecognized. We analyzed 164,441 participants in the Veterans

Plasma biomarkers of cardiometabolic health are invaluable tools for cardiovascular disease (CVD) and type 2 diabetes (T2D) risk stratification. Data driven patient classification may offer unbiased insights into dominant biologic risk factors that determine avenues for risk reduction. We conducted

As biologic, epidemiologic, and clinical trial data have demonstrated, inflammation is a key driver of atherosclerosis. Circulating biomarkers of inflammation, including high-sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6), are associated with increased risk of cardiovascular events independent of cholesterol and other traditional risk factors. Randomized trials have shown that statins reduce hsCRP, and the magnitude of hsCRP reduction is proportional to the reduction in cardiovascular risk. Additionally, these trials have demonstrated that many individuals remain at increased risk due to persistent elevations in hsCRP despite significant reductions in low-density lipoprotein cholesterol (LDL-C) levels. This “residual inflammatory risk” has increasingly become a viable pharmacologic target. In this review, we summarize the data linking inflammation to atherosclerosis with a particular focus on residual inflammatory risk. Additionally, we detail the results of Canakinumab Anti-inflammatory Thrombosis Outcome Study (CANTOS), which showed that directly reducing inflammation with an IL-1β antagonist reduces cardiovascular event rates independent of LDL-C. These positive data are contrasted with neutral evidence from CIRT in which low-dose methotrexate neither reduced the critical IL-1β to IL-6 to CRP pathway of innate immunity, nor reduced cardiovascular event rates.

PURPOSE OF REVIEW: Numerous studies have begun to unravel the genetic basis of not only aortic disease but also other forms of commonly encountered vascular diseases. The goal of this review is to provide clinicians a reference to help identify and diagnose different types of vascular disease with a genetic underpinning. RECENT FINDINGS: Ongoing studies have identified numerous genes involved in the TGF-β signaling pathway that are also associated with thoracic aortic aneurysm and dissection, and it is possible to test for pathogenic variants in these genes in the clinical setting using commercially available genetic testing panels. Additional studies have begun to identify genetic variants associated with an increased risk of bicuspid aortic valve, abdominal aortic aneurysm, and fibromuscular dysplasia. SUMMARY: With increased availability of low-cost genetic testing, clinicians are now able to not only definitively diagnose some vascular syndromes but also provide information on the risk of disease in other family members, as well as provide guidance in terms of family planning. As the cost of genetic testing continues to drop with the benefit of increasing insurance coverage, genetic data will increasingly become part of clinical care for many patients with vascular disease.

Despite strong and consistent prospective associations of elevated low-density lipoprotein (LDL) cholesterol concentration with incident coronary and cerebrovascular disease, data for incident peripheral artery disease (PAD) are less robust. Atherogenic dyslipidemia characterized by increased small LDL particle (LDL-P) concentration, rather than total LDL cholesterol content, along with elevated triglyceride-rich lipoproteins and low high-density lipoprotein (HDL) cholesterol (HDL-C), may be the primary lipid driver of PAD risk.The study population was a prospective cohort study of 27 888 women ≥45 years old free of cardiovascular disease at baseline and followed for a median of 15.1 years. We tested whether standard lipid concentrations, as well as nuclear magnetic resonance spectroscopy-derived lipoprotein measures, were associated with incident symptomatic PAD (n=110) defined as claudication and/or revascularization.In age-adjusted analyses, while LDL cholesterol was not associated with incident PAD, we found significant associations for increased total and small LDL-P concentrations, triglycerides, and concentrations of very LDL (VLDL) particle (VLDL-P) subclasses, increased total cholesterol (TC):HDL-C, low HDL-C, and low HDL particle (HDL-P) concentration (all P for extreme tertile comparisons0.05). Findings persisted in multivariable-adjusted models comparing extreme tertiles for elevated total LDL-P (adjusted hazard ratio [HRIn this prospective study, nuclear magnetic resonance-derived measures of LDL-P, but not LDL cholesterol, were associated with incident PAD. Other features of atherogenic dyslipidemia, including elevations in TC:HDL-C, elevations in triglyceride-rich lipoproteins, and low standard and nuclear magnetic resonance-derived measures of HDL, were significant risk determinants. These data help clarify prior inconsistencies and may elucidate a unique lipoprotein signature for PAD compared to coronary and cerebrovascular disease.URL: https://www.clinicaltrials.gov/ . Unique Identifier: NCT00000479.

Information about a real patient is presented in stages (boldface type) to expert clinicians (Drs Beckman and Sobieszczyk), who respond to the information and share their reasoning with the reader (regular type). A discussion by the authors follows. Patient presentation: An otherwise healthy 29-year-old white woman presented to our emergency department with leg pain and edema. She was well until 2 weeks before, when she developed lower back pain following a 3-hour flight. Her pain progressed despite treatment with ice packs, nonsteroidal anti-inflammatory drugs, and stretching, and it became so severe that she was unable to sit comfortably at work. Five days before presentation, she began noticing tightness in both thighs and subtle swelling of both legs, as well. Over the subsequent 48 hours, she experienced rapidly worsening bilateral lower extremity swelling, primarily in her thighs, accompanied by pain in her legs. She denied dyspnea, palpitations, chest pain, abdominal distension, or lightheadedness. Her symptoms worsened to the point where ambulation was difficult, thus prompting her visit to the emergency department. Additional medical history was notable for no previous illnesses or surgeries. Medications included ethinyl estradiol and levonorgestrel (a combination oral contraceptive). She had no known drug allergies. She denied tobacco or illicit drug use and consumed alcohol in moderation. There was no family history of venous thromboembolism (VTE), stroke, or sudden death. Dr Beckman: Lower extremity edema is commonly seen in both right- and left-sided heart failure, and in individuals with advanced liver and kidney disease, as well. However, this case is notable for the rapid progression of her symptoms, and the lack of dyspnea or other symptoms suggestive of cardiopulmonary disease. Her description of severe pain, tension, and swelling in her extremities indicates significant impairment to venous drainage, which is most likely caused by deep vein thrombosis (DVT). Although …

As genomic testing becomes more accessible for both clinical indications and patients’ personal curiosity, cardiologists are increasingly asked to interpret the results in terms of future risk of disease. In many cases, patients hope that such testing will yield detailed, personalized recommendations regarding their own medical care as well as their family’s. However, given the lack of formal instruction in genomic analysis during cardiovascular training, a gap exists between some patients’ desires and our own abilities to incorporate genomic information into practice. Patient care and biomedical research will undoubtedly be increasingly influenced by genomic medicine efforts in the coming years. In his 2016 budget proposal, President Obama allocated $215 million to fund the Precision Medicine Initiative.1 The goal of this program is to develop data lakes compiling vast arrays of patient data, including genomic information and detailed phenotypic, epigenomic, proteomic, transcriptomic, and metabolomic data. By using the computational power of such an effort, clinicians will hopefully be able to better predict disease and tailor therapies at the population and individual levels. Given the enormous resource investment and global burden of cardiovascular disease, the cardiovascular community will likely play a key role in this movement. Therefore, it is critical that we begin to incorporate training modules on genomic …

Numerous cross-sectional studies of venous thromboembolism (VTE) have identified plasma homocysteine as a potential risk factor for VTE. In contrast, prospective data are sparse with limited studies conducted among women. Given current interest in expanded indications for anticoagulation therapy, we

Background: Although the resting ankle-brachial index (ABI) is commonly used to diagnose peripheral artery disease (PAD), limited data suggest several indices measured after exercise may have increased sensitivity for identifying PAD. The aim of this study was to determine the utility of resting ABI

Intravenous sedation and analgesia are important therapies during mechanical ventilation (MV). However, daily interruption of these medications is associated with improved outcomes in mechanically ventilated patients. We tested a clinical pathway for the use of sedation and analgesia during MV in a cardiac intensive care unit (CICU).We evaluated all mechanically ventilated patients in a CICU during two phases: phase 1 prior to pathway implementation (PRE) and phase 2 post-pathway implementation (POST). A total of 198 patients (98 PRE and 100 POST) and 1012 days of intubation (574 PRE and 434 POST) were included in this analysis. We found an increase in the frequency of daily interruptions of sedation post-implementation (49.3% PRE and 58.4% POST, p=0.0041). There was a significant decrease in the mean duration of MV in the POST vs PRE periods (5.0±2.3 vs 6.1±2.8 days, p=0.015). There was also a significant decrease in total neuroimaging studies (9 vs 49, p=0.001) and a trend toward a decrease in tracheostomies (3.0% vs 6.1%, p=0.33). Mean CICU length of stay (LOS) and hospital LOS respectively were 10.4 days and 16.8 days PRE and 10.4 days and 17.9 days POST (p=0.99 and p=0.55). Mortality did not differ (PRE 36.7% vs POST 32.0% p=0.55).Implementation of a pragmatic pathway for sedation and analgesia in a CICU was associated with an increase in the daily interruption of sedation and a corresponding decrease in the duration of MV days and the need for neuroimaging.

An organism's genome sequence serves as a blueprint for the proteins and regulatory RNAs essential for cellular function. The genome also harbors cis-acting non-coding sequences that control gene expression and are essential to coordinate regulatory programs during embryonic development. However, the genome sequence is largely identical between cell types within a multi-cellular organism indicating that factors such as DNA accessibility and chromatin structure play a crucial role in governing cell-specific gene expression. Recent studies have identified particular chromatin modifications that define functionally distinct cis regulatory elements. Among these are forms of histone 3 that are mono- or tri-methylated at lysine 4 (H3K4me1 or H3K4me3, respectively), which bind preferentially to promoter and enhancer elements in the mammalian genome. In this work, we investigated whether these modified histones could similarly identify cis regulatory elements within the zebrafish genome. By applying chromatin immunoprecipitation followed by deep sequencing, we find that H3K4me1 and H3K4me3 are enriched at transcriptional start sites in the genome of the developing zebrafish embryo and that this association correlates with gene expression. We further find that these modifications associate with distal non-coding conserved elements, including known active enhancers. Finally, we demonstrate that it is possible to utilize H3K4me1 and H3K4me3 binding profiles in combination with available expression data to computationally identify relevant cis regulatory sequences flanking syn-expressed genes in the developing embryo. Taken together, our results indicate that H3K4me1 and H3K4me3 generally mark cis regulatory elements within the zebrafish genome and indicate that further characterization of the zebrafish using this approach will prove valuable in defining transcriptional networks in this model system.