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South Asians (SA) experience disproportionately higher rates of atherosclerotic cardiovascular disease (ASCVD). We evaluated prevalence, patterns, and determinants of advanced coronary artery calcium (CAC) measures (specific coronary vessel involvement, plaque volume and density) in SA versus other

Stroke, a leading cause of death and disability, is most prevalent in elderly, but occurs not uncommonly in the young (

Familial hypercholesterolemia (FH) is associated with premature atherosclerotic cardiovascular disease (ASCVD). However, ASCVD risk is heterogeneous in individuals with FH and coronary artery calcium (CAC) can further risk stratify this population. Our objective was to determine the cost

In the recently published review "Coronary Artery Calcium: Recommendations for Risk Assessment in Cardiovascular Prevention Guidelines," the following author name was inadvertently misspelled as Alison Peng. The correct spelling of the author's name is: Allison Peng as shown above.

In this review, we evaluate the coronary artery calcium (CAC) score as a biomarker for advanced atherosclerotic cardiovascular disease (ASCVD) risk assessment. We summarize the evidence from multiple epidemiological studies, which show a clear advantage of CAC compared to traditional and non-traditional cardiovascular risk factors. We then compare the recommendations included in the 2013 American College of Cardiology/American Heart Association (ACC/AHA) and in the 2017 Society of Cardiovascular Computed Tomography (SCCT) guidelines for the use of CAC in ASCVD risk assessment, and examine the recent 2018 US Preventive Services Task Force (USPSTF) document. Finally, based on the currently available evidence, we provide constructive input for the upcoming ACC/AHA guidelines, regarding the population in whom CAC is most likely to be informative, the level of evidence that we believe should be assigned to CAC as an advanced ASCVD risk assessment tool, and the special populations in whom CAC might be beneficial for further risk assessment. We support a pragmatic approach that combines the pooled cohort equations (PCE) for initial ASCVD risk stratification, followed by CAC for refining ASCVD risk assessment among a broad range of intermediate risk patients and other special groups.

Background The efficacy of telemedicine in the management of patients with chronic heart failure and left ventricular ejection fraction ≥40% is poorly understood. The aim of our analysis was to evaluate the efficacy of a telemedicine-based intervention specifically in these patients, as compared to standard of care alone. Methods The Insuficiència Cardiaca Optimització Remota (iCOR) study was a single centre, randomised, controlled trial, designed to evaluate a telemedicine intervention added to an existing hospital/primary care multidisciplinary, integrated programme for chronic heart failure patients. 178 participants were randomised to telemedicine or usual care, and were followed for six months. For the present sub-analysis, only iCOR participants (n = 116) with left ventricular ejection fraction ≥40% were included. The primary study endpoint was the incidence of an acute non-fatal heart failure event, defined as a new episode of worsening of symptoms and signs consistent with acute heart failure requiring intravenous diuretic therapy. The healthcare-related costs in each study group were also evaluated. Results The incidence of the first occurrence of the primary endpoint was significantly lower in the telemedicine arm (22% vs 56%, pConclusions Our results suggest that telemedicine is a promising strategy for the management of chronic heart failure patients with left ventricular ejection fraction ≥40%. These findings should be replicated in larger cohorts.

Background and aims We aimed to evaluate the associations and prognostic value of interleukin-6 (IL6) for the prediction of atherosclerotic cardiovascular disease (ASCVD) events, heart failure (HF), and other chronic diseases in a large, multi-ethnic, contemporary population. Methods We included 6617 participants from the Multi-Ethnic Study of Atherosclerosis (5640 non-users, 977 users of statins at baseline). Main outcomes were hard ASCVD events and HF; secondary outcomes included all-cause death, atrial fibrillation, venous thromboembolism and cancer. Results Median follow-up was 13.2 years. Strong associations were observed in Cox regression analyses between higher IL6 levels and ASCVD events, HF, and mortality, particularly among statins users. In the latter, associations remained strong after adjusting for traditional risk factors and other inflammation biomarkers (e.g., risk factor, hsCRP-adjusted hazard ratio for incident HF comparing 3rd vs. 1st IL6 tertiles: 3.55, 95% CI 1.23–10.27). Although IL6 did not improve CHD prediction beyond traditional risk factors, among statin users it improved the prediction of stroke (improvement in the C statistic +0.018), incident HF (+0.028, the largest C statistic increase across all study outcomes), and all-cause death (+0.017). Conclusions IL6 is strongly and independently associated with ASCVD events, HF, and all-cause mortality, particularly among statin users. Although the prognostic value of IL6 is limited for the prediction of CHD events, it may have a role for the prediction of stroke, HF and all-cause death in asymptomatic statin users. Larger studies are needed to replicate these findings.

BACKGROUND: The optimal noninvasive test (NIT) for patients with diabetes and stable symptoms of coronary artery disease (CAD) is unknown. OBJECTIVE: To assess whether a diagnostic strategy based on coronary computed tomographic angiography (CTA) is superior to functional stress testing in reducing adverse cardiovascular (CV) outcomes (CV death or myocardial infarction [MI]) among symptomatic patients with diabetes. METHODS: The Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE; NCT01174550) was a randomized trial evaluating an initial strategy of CTA versus functional testing in stable outpatients with symptoms suggestive of CAD. We compared CV outcomes in patients with diabetes (n=1,908 [21%]) and without diabetes (n=7,058 [79%]) based on their randomization to CTA or functional testing. RESULTS: Patients with diabetes (vs. without) were similar in age (median 61 vs. 60 years) and sex (female 54% vs. 52%) but had a greater burden of CV comorbidities. Patients with diabetes who underwent CTA had a lower risk of CV death/MI, compared to functional stress testing (CTA, 1.1% [10/936] vs. stress testing, 2.6% [25/972]; adjusted hazard ratio [aHR] 0.38, 95% CI 0.18–0.79; p=0.01). There was no significant difference in non-diabetics (CTA, 1.4% [50/3,564] vs. stress testing, 1.3% [45/3,494]; aHR 1.03, 95% CI 0.69–1.54, p=0.887; interaction term for diabetes p-value=0.02). CONCLUSIONS: In diabetics presenting with stable chest pain, a CTA strategy resulted in fewer adverse CV outcomes than a functional testing strategy. CTA may be considered as the initial diagnostic strategy in this subgroup.

To discuss the classic analogy of “coronary artery calcium (CAC) as a mammogram of the heart”, by evaluating the conceptual strengths, weaknesses, opportunities, and threats of a potential cardiovascular disease (CVD) screening strategy using CAC in apparently healthy adults. CAC is typically used for further CVD risk assessment. CAC is also currently being used as a screening test in specific subgroups of individuals, particularly in some Asian countries. Although this has yielded valuable insights on the determinants and pathophysiology of CVD, whether this approach results in improved clinical outcomes compared to other assessment and management approaches is currently unclear. Although CAC and mammograms share a number of characteristics, there are also important conceptual differences. The evidence supporting CAC, which is a robust CVD risk assessment tool, for CVD screening purposes is currently very limited, and further research is needed.

Vascular erectile dysfunction (ED) and cardiovascular disease (CVD) share common risk factors including obesity, hypertension, metabolic syndrome, diabetes mellitus, and smoking. ED and CVD also have common underlying pathological mechanisms, including endothelial dysfunction, inflammation, and atherosclerosis. 1 Despite these close relationships, the evidence documenting ED as an independent predictor of future CVD events is limited. We therefore leveraged the MESA study (Multi-Ethnic Study of Atherosclerosis), an ethnically diverse, community-based, multisite prospective cohort study, to examine the value of self-reported ED for predicting incident coronary heart disease (CHD) and CVD in those free of these CVD events at baseline. Details of MESA have been described previously. 2 Male MESA participants who attended visit 5 and answered the single Massachusetts Male Aging Study question 3 on ED symptoms were considered for our analysis (n=1914). A participant was considered to have ED if he responded "never able" or "sometimes able" to the Massachusetts Male Aging Study question. After excluding 155 participants with a CVD event before visit 5, 1757 participants were followed for 3.8 years (interquartile range, 3.5-4.2) and outcomes of hard CHD and CVD events were assessed. Hard CVD events included all hard CHD events (myocardial infarction, resuscitated cardiac arrest, and CHD death), plus stroke and stroke death. Participants provided informed consent, and each study site obtained approval from their institutional review board.

Objective To describe the prevalence of Spanish workers with Metabolic Syndrome (MetS) and those at risk of developing MetS in 2015. Methods Cross-sectional study of workers (n = 15 614). We used a modified definition of the NCEP:ATPIII criteria for MetS (we used body mass index (BMI) above 28.8 kg/m2 instead of the waist circumference criterion). We calculated the prevalence of MetS (having at least three components) and of being at risk of MetS (having one or two components). We calculated adjusted odds ratios (aOR) of MetS according to socio-economic and workplace characteristics. Results The proportions of workers with and at risk of MetS were 7.1 and 31.9%, respectively. The most prevalent criterion was having a BMI > 28.8 kg/m2 (24.1%) in men and cHDL < 40 mg/dl in women (12.9%). There were significant associations between MetS and men (aOR compared to women = 3.73, CI 95%: 3.19; 4.36); age (higher among oldest, aOR = 5.75, CI 95%: 4.37;7.56); and social class (higher among lower social class, aOR = 2.03, CI 95%: 1.65;2.48). Conclusion Reducing any of the five MetS components, while taking into account the differences found by socio-economic and workplace characteristics, should be one priority for reducing MetS prevalence.

In 2018, cardiovascular disease (CVD) was the leading cause of death among women, and current CVD prevention paradigms may not be sufficient in this group. In that context, it has recently been proposed that detection of calcification in breast arteries may help improve CVD risk screening and assessment in apparently healthy women. This review provides an overview of breast arterial anatomy; and the epidemiology, pathophysiology, and measurement of breast artery calcium (BAC); and discusses the features of the BAC-CVD link. The potential clinical applications that BAC may offer for CVD prevention in the context of current clinical practice guidelines and recommendations are also discussed. Finally, current gaps in evidence gaps are outlined, and future directions in the field are explored with a focus on the implementation of BAC mammography as a CVD risk-screening tool in routine clinical practice.

Our purpose was to discuss the methodological limitations of observational nutritional epidemiology research, using observational studies on coffee intake and health as a case example. A number of recent observational studies on the potential health effects of daily coffee intake have reported protective associations between higher coffee intake and a variety of health outcomes, including death. This is inconsistent with the findings from classic studies showing an increased risk of coronary heart disease events, performed in young adults with a homogeneous education level, and adjusting for tobacco use. Many nutritional epidemiological studies have important limitations, which limit their validity. These include the use of prevalent user designs, risk of reverse causality, measurement error particularly of the exposure of interest, and residual confounding by socioeconomic status. In this review, we discuss these potential issues and provide constructive recommendations intended to help minimize them.

Background The effect of chronic hepatitis B virus (HBV) infection on the risk of chronic kidney disease (CKD) is controversial. We examined the prospective association between hepatitis B surface antigen (HBsAg) serology status and incident CKD in a large cohort of men and women. Methods Cohort study of 299,913 adults free of CKD at baseline who underwent health screening exams between January 2002 and December 2016 in South Korea. Incident CKD was defined as the development of an estimated glomerular filtration rate (eGFR)

Objective— Short and long sleep duration are associated with increased risk of clinical cardiovascular events, but the association between sleep duration and subclinical cardiovascular disease is not well established. We examined the association between sleep duration and sleep quality with coronary artery calcification (CAC) and with brachial–ankle pulse wave velocity (PWV) in a large sample of young and middle-aged asymptomatic adults. Approach and Results— We conducted a cross-sectional study of adult men and women who underwent a health checkup examination, including assessment of sleep duration and quality and coupled with either CAC (n=29 203) or brachial–ankle PWV (n=18 106). The multivariate-adjusted CAC score ratios (95% confidence interval) comparing sleep durations of ≤5, 6, 8, and ≥9 hours with 7 hours of sleep were 1.50 (1.17–1.93), 1.34 (1.10–1.63), 1.37 (0.99–1.89), and 1.72 (0.90–3.28), respectively ( P for quadratic trend=0.002). The corresponding average differences in brachial–ankle PWV were 6.7 (0.75–12.6), 2.9 (−1.7 to 7.4), 10.5 (4.5–16.5), and 9.6 (−0.7 to 19.8) cm/s, respectively ( P for quadratic trend=0.019). Poor subjective sleep quality was associated with CAC in women but not in men, whereas the association between poor subjective sleep quality and brachial–ankle PWV was stronger in men than in women. Conclusions— In this large study of apparently healthy men and women, extreme sleep duration and poor subjective sleep quality were associated with increased prevalence of CAC and higher PWV. Our results underscore the importance of an adequate quantity and quality of sleep to maintain cardiovascular health.

The 2013 American College of Cardiology/American Heart Association cardiovascular disease prevention guidelines represent an important step forward in the risk assessment and management of atherosclerotic cardiovascular disease in clinical practice. Differentiated risk prediction equations for women and black individuals were developed, and convenient 10-year and lifetime risk assessment tools were provided, facilitating their implementation. Lifestyle modification was portrayed as the foundation of preventive therapy. In addition, based on high-quality evidence from randomized controlled trials, statins were prioritized as the first lipid-lowering pharmacologic treatment, and a shared decision-making model between the physician and the patient was emphasized as a key feature of personalized care. After publication of the guidelines, however, important limitations were also identified. This resulted in a constructive scientific debate yielding valuable insights into potential opportunities to refine recommendations, fill gaps in guidance, and better harmonize recommendations within and outside the United States. The latter point deserves emphasis because when guidelines are in disagreement, this may result in nonaction on the part of professional caregivers or nonadherence by patients. In this review, we discuss the key scientific literature relevant to the guidelines published in the year and a half after their release. We aim to provide cohesive, evidence-based views that may offer pathways forward in cardiovascular disease prevention toward greater consensus and benefit the practice of clinical medicine.

Objective: To evaluate the association between brachial-ankle pulse wave velocity (baPWV), a convenient, non-radiating, readily available measurement of arterial stiffness, and coronary artery calcium (CAC), a reliable marker of coronary atherosclerosis, in a large sample of young and middle-aged asymptomatic adults; and to assess the incremental value of baPWV for detecting prevalent CAC beyond traditional risk factors. Methods: Cross-sectional study of 15,185 asymptomatic Korean adults who voluntarily underwent a comprehensive health screening program including measurement of baPWV and CAC. BaPWV was measured using an oscillometric method with cuffs placed on both arms and ankles. CAC burden was assessed using a multi-detector CT scan and scored following Agatston's method. Results: The prevalence of CAC > 0 and CAC > 100 increased across baPWV quintiles. The multivariableadjusted odds ratios (95% CI) for CAC > 0 comparing baPWV quintiles 2e5 versus quintile 1 were 1.06 (0.87e1.30), 1.24 (1.02e1.50), 1.39 (1.15e1.69) and 1.60 (1.31e1.96), respectively (P trend 100 were 1.30 (0.74e2.26), 1.59 (0.93e2.71), 1.74 (1.03 e2.94) and 2.59 (1.54e4.36), respectively (P trend 100, the area under the ROC curve for baPWV alone was 0.71 (0.68e0.74), and the addition of baPWV to traditional risk factors significantly improved the discrimination and calibration of models for detecting prevalent CAC > 0 and CAC > 100. Conclusions: BaPWV was independently associated with the presence and severity of CAC in a large sample of young and middle-aged asymptomatic adults. BaPWV may be a valuable tool for identifying apparently low-risk individuals with increased burden of coronary atherosclerosis. © 2015 Published by Elsevier Ireland Ltd.

Background A Methods One hundred and thirty-four patients (age 67 ± 13 years, 78% males) undergoing successful CTI ablation were included and divided into 2 groups: Group 1 (n = 68), in which ablation was performed before the IP maneuver was incorporated, with CTI block confirmed by at least 1 non-local and 1 local electrogram-based previously established criteria; and Group 2 (n = 66), in which IP maneuver was used to confirm complete CTI block. Results No intergroup differences were noted in baseline characteristics, ablation settings and fluoroscopy/radiofrequency times. Long-term AFL recurrences were observed in 14 out of 134 patients (10.4%), and were more common in Group 1 (19%, vs 1.5% among Group 2 patients, p Conclusions The addition of the IP maneuver for the diagnosis of complete CTI block reduces AFL long-term recurrences after ablation.

Atherosclerosis is a systemic disease. We examined whether the cumulative burden of thoracic extra-coronary calcification (ECC) improves prediction of stroke, transient ischemic attack (TIA), and stroke mortality beyond traditional risk factors and coronary artery calcium (CAC).We followed a total of 6805 participants (mean age 62.1 ± 10.2 years, 47.2% male) from the Multi-Ethnic Study of Atherosclerosis (MESA) over a median of 12.1 years. The presence or absence of calcification at 4 thoracic ECC sites (mitral valve annulus, aortic valve, aortic root, and thoracic aorta) was determined from baseline cardiac-gated non-contrast CT scans. A multisite thoracic ECC score, ranging 0-4, was calculated by summing the 4 individual sites, which were treated as binary variables. Multivariable Cox proportional hazards regression models, controlled for traditional risk factors and CAC, were used to estimate hazard ratios for ischemic (primary endpoint) and hemorrhagic stroke, total stroke, TIA, and stroke mortality with increasing thoracic ECC.With an increasing number of thoracic ECC sites, there was a significant (p 0.10).Although multisite thoracic ECC is independently associated with ischemic stroke, total stroke, and TIA, the incremental predictive value of thoracic ECC beyond traditional risk factors and CAC appears to be minimal.

Purpose: To report and discuss estimated prevalence of potential off-label use and associated methodological challenges using a case study of dabigatran. Methods: Observational, cross-sectional study using 3 databases with different types of clinical information available: Cegedim Strategic Data Longitudinal Patient Database (CSD-LPD), France (cardiologist panel, n = 1706; general practitioner panel, n = 2813; primary care data); National Health Databases, Denmark (n = 28 619; hospital episodes and dispensed ambulatory medications); and Clinical Practice Research Datalink (CPRD), UK (linkable to Hospital Episode Statistics [HES], n = 2150; not linkable, n = 1285; primary care data plus hospital data for HES-linkable patients). Study period: August 2011 to August 2015. Two definitions were used to estimate potential off-label use: a broad definition of on-label prescribing using codes for disease indication (eg, atrial fibrillation [AF]), and a restrictive definition excluding patients with conditions for which dabigatran is not indicated (eg, valvular AF). Results: Prevalence estimates under the broad definition ranged from 5.7% (CPRD-HES) to 34.0% (CSD-LPD) and, under the restrictive definition, from 17.4% (CPRD-HES) to 44.1% (CSD-LPD). For the majority of potential off-label users, no diagnosis potentially related to anticoagulant use was identified. Key methodological challenges were the limited availability of detailed clinical information, likely leading to overestimation of off-label use, and differences in the information available, which may explain the disparate prevalence estimates across data sources. Conclusions: Estimates of potential off-label use should be interpreted cautiously due to limitations in available information. In this context, CPRD HES-linkable estimates are likely to be the most accurate.

Quantification of coronary artery calcium (CAC) has been shown to be reliable, reproducible, and predictive of cardiovascular risk. Formal CAC scoring was introduced in 1990, with early scoring algorithms notable for their simplicity and elegance. Yet, with little evidence available on how to best build a score, and without a conceptual model guiding score development, these scores were, to a large degree, arbitrary. In this review, we describe the traditional approaches for clinical CAC scoring, noting their strengths, weaknesses, and limitations. We then discuss a conceptual model for developing an improved CAC score, reviewing the evidence supporting approaches most likely to lead to meaningful score improvement (for example, accounting for CAC density and regional distribution). After discussing the potential implementation of an improved score in clinical practice, we follow with a discussion of the future of CAC scoring, asking the central question: do we really need a new CAC score?

Background and aimsTAC is associated with incident CVD and all-cause mortality. Nevertheless, the independent 10-year prognostic value of TAC in individuals with CAC=0 beyond traditional risk factors is not well established.Methods3415 MESA participants with baseline CAC=0 were followed for CHD, CVD events and all-cause mortality. TAC was measured in the ascending and descending aorta in all participants and quantified using Agatston's score. Multivariable Cox proportional hazards regression models were used to study the associations between TAC and incident CHD, CVD events and all-cause mortality. Likelihood ratio tests were used to compare prediction models including traditional risk factors plus TAC versus risk factors alone.Results406 participants (11.9%) had TAC>0at baseline. Over a median follow-up of 11.3 years, unadjusted event rates per 1000 person-years were higher in TAC>0 than in TAC=0 participants: CHD 2.18 vs. 2.03; CVD 6.85 vs. 3.42; all-cause mortality 12.84 vs. 4.96. However, in multivariable Cox regression analyses adjusting for CVD risk factors, neither TAC>0, TAC>100 nor log(TAC+1) were independently associated with any of the study outcomes, nor improved their prediction compared to traditional risk factors alone (p value of likelihood ratio tests >0.05).ConclusionsIn a multi-ethnic, modern US population of asymptomatic individuals with CAC=0at baseline, the prevalence of TAC>0 was low, and TAC did not improve 10-year estimation of prognosis beyond traditional risk factors. In the presence of CAC=0, measurement of TAC is unlikely to provide sufficient additional prognostic information to further improve risk assessment.

The role of hepatitis virus infection in glucose homeostasis is uncertain. We examined the associations between hepatitis B virus (HBV) or hepatitis C virus (HCV) infection and the development of diabetes in a cohort (N = 439,708) of asymptomatic participants in health screening examinations. In cross-sectional analyses, the multivariable-adjusted odds ratio for prevalent diabetes comparing hepatitis B surface antigen (HBsAg) (+) to HBsAg (−) participants was 1.17 (95% CI 1.06–1.31; P = 0.003). The corresponding odds ratio comparing hepatitis C antibodies (HCV Ab) (+) to HCV Ab (−) participants was 1.43 (95% CI 1.01–2.02, P = 0.043). In prospective analyses, the multivariable-adjusted hazard ratio for incident diabetes comparing HBsAg (+) to HbsAg (−) participants was 1.23 (95% CI 1.08–1.41; P = 0.007). The number of incident cases of diabetes among HCV Ab (+) participants (10 cases) was too small to reliably estimate the prospective association between HCV infection and diabetes. In this large population at low risk of diabetes, HBV and HCV infections were associated with diabetes prevalence and HBV infection with the risk of incident diabetes. Our studies add evidence suggesting that diabetes is an additional metabolic complication of HBV and HCV infection.

We have read the recent study by Wadhera et al. [(1)][1] with great interest. Rising direct health care costs associated with pandemic conditions such as chronic heart failure (CHF) are becoming major threats to the sustainability of health care systems in most Western countries. This concern has

Introduction Previous studies report an association between elevated heart rate (HR) and increased mortality and rehospitalizations in patients with HFrEF and have also found that reduction in HR reduced HF rehospitalization. Hypothesis: We hypothesized that for patients with an index HFrEF-related hospital admission, HR at discharge and change in HR between hospital admission and discharge would be associated with subsequent increased risk for rehospitalization. Methods 180 US physicians contributed record abstraction data for patients hospitalized with a confirmed, primary diagnosis of HFrEF defined as LVEF ≤35% + ≥1 at admission: administration of an IV diuretic, BNP levels >200pg/mL, or N-terminal proBNP levels >600pg/mL. The association of HR at discharge and change in HR from admission to discharge with rehospitalization at any time post-discharge were assessed using multivariable Cox regression analysis. Results 1002 patients (63% male, mean±SD age 62.5±13.3y, LVEF 27.2±6.0%) were included. At admission, 59% of patients were prescribed beta blockers (BB); 48%, ACE inhibitors (ACEi); and ARBs, 17%. At discharge, 71% received BB; 54%, ACEi; and 19%, ARBs. Among all patients, 39% had ≥1 post-discharge rehospitalization anytime (14% within 30 days). Mean HR at discharge was 73.51±11.47. HR at discharge of >80bpm (n=188) had a trend towards increased rehospitalization (hazard ratio=1.28, CI 0.98-1.68, P=0.07). The mean change in HR from admission to discharge was −19.5±17.2bpm. Mean change in HR correlated significantly with rehospitalization rate. Patients with >0%-20% reduction in HR (hazard ratio=0.61, 95%CI 0.43-0.85, P=0.004) and >20% reduction (0.62, 0.45-0.87, P=0.005) were less likely to be rehospitalized when compared to patients with no change or an increase (Figure). Conclusions In patients with HFrEF receiving similar treatment as reported in large registries, a reduction in HR during a HFrEF-related admission is associated with reduced rehospitalization. Further investigation of clinical drivers of change in HR could potentially identify management strategies to reduce rehospitalization.

Introduction: High systemic inflammation and low levels of exercise are associated with increased risk of cancer. We hypothesized that in the setting of inflammation, exercise mitigates cancer risk. Methods: To address this, we identified 6,388 participants, free of cancer and cardiovascular disease, enrolled in the Multi-Ethnic Study of Atherosclerosis. Regular moderate/vigorous intentional exercise was categorized as present or absent based on self-report from validated questions. A composite inflammatory score was created with a point given for C-reactive protein, IL-6, fibrinogen, and GlycA above normal, with composite scores > 2 points categorized as high. Cancer incidence was ascertained based on ICD codes abstracted from hospitalization or cancer registry data. Cox proportional hazard models were used to calculate subsequent risk of incident cancer. Models were adjusted for baseline age, gender, race, pack years smoking, education, income, health insurance status, body mass index, high-density lipoprotein levels, healthy diet adherence, statin and aspirin use. Results: The mean age was 62 years (±10.2 years), 53% female, 39% white, 26% black, 22% Hispanic, and 12% Chinese-American. Compared to the reference group (individuals reporting no exercise and with low levels of inflammation), in multi-variable adjusted models, individuals with high levels of inflammation and no exercise were at highest risk of cancer (hazard ratio = 1.17; 95% confidence interval 1.00 – 1.37), while those with low levels of inflammation who exercised were at the lowest risk of cancer (HR 0.80, 95% CI 0.68-0.95). Those who had high levels of inflammation, but regular exercise had no increased risk of cancer (HR 0.94, 95% CI 0.68-1.30). There was no significant interaction between exercise and inflammation. When considering individual inflammatory markers, there was a similar pattern (Table). Conclusion: Intentional moderate/vigorous exercise may lower the risk of cancer in individuals with high versus low levels of chronic inflammation. Cox proportional hazard models for incident cancer by exercise and measures of inflammation, adjusteno exerciseany exerciseHR95% CIHR95% CILow composite score (0 - 1)Ref0.800.680.95High composite score (>2)1.171.001.370.940.681.30P for interaction = 0.25Low CRP (2 mg/L)1.231.051.430.980.711.35P for interaction = 0.94Low IL-6 (< 1.8 pg/mL)Ref0.800.680.95High IL-6 (>1.8 pg/mL)1.070.911.260.860.621.19P for interaction = 0.18Low GlycA (400 µmol/L)1.191.021.390.960.691.32P for interaction = 0.73Low fibrinogen (450 mg/dL)0.970.751.250.770.511.18P for interaction = 1.00 Citation Format: Catherine Handy Marshall, Zeina Dardari, Miguel Cainzos-Achirica, Martin B. Mortensen, Khurram Nasir, Mouaz H. Al-Mallah, Michael D. Miedema, Ron Blankstein, Roger S. Blumenthal, Kala Visvanathan, Michael J. Blaha. Exercise and inflammation on the risk of cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 5056.

ObjectiveTo describe the prevalence and incidence of cardiovascular risk factors, established cardiovascular disease (CVD) and cardiovascular medication use, among immigrant individuals of diverse national origins living in Catalonia (Spain), a region receiving large groups of immigrants from all around the world, and with universal access to healthcare.MethodsWe conducted a population-based analysis including >6 million adult individuals living in Catalonia, using the local administrative healthcare databases. Immigrants were classified in 6 World Bank geographic areas: Latin America/Caribbean, North Africa/Middle East, sub-Saharan Africa, East Asia and South Asia. Prevalence calculations were set as of 31 December 2017.ResultsImmigrant groups were younger than the local population; despite this, the prevalence of CVD risk factors and of established CVD was very high in some immigrant subgroups compared with local individuals. South Asians had the highest prevalence of diabetes, and of hyperlipidemia among adults aged ConclusionsThe high prevalence of risk factors and established CVD among South Asians and sub-Saharan Africans stresses the need for tailored, aggressive health promotion interventions. These are likely to be beneficial in Catalonia, and in countries receiving similar migratory fluxes, as well as in their countries of origin.

The inherent limitations of traditional risk factor-based cardiovascular disease (CVD) risk assessment [1] have triggered the development and implementation of imaging tests aimed at directly measuring the presence and burden of subclinical atherosclerosis in diverse vascular beds within individual patients. Such individualized disease assessment clearly trumps risk factors as the strongest predictor of incident CVD events and death [2]. The promising results of incorporating such imaging-based risk information into clinical decision-making has led experts to advance a CVD risk assessment paradigm shift from a risk-factor based model (prediction) to an atherosclerosis imaging-based approach (disease detection). Among available imaging modalities, coronary artery calcium (CAC) using non-contrast computed tomography is considered one of the most powerful tools for absolute CVD risk assessment in asymptomatic adults [3]. Notwithstanding its essential limitation for ruling out the presence of early non-calcified plaque, CAC has a very high sensitivity for the detection of clinically relevant coronary atherosclerosis in asymptomatic adults [4], which results in a high negative predictive value. Moreover, CAC appears particularly valuable as a prognostic test. Beyond its well-known ability to identify those individuals more likely to have CVD events

Background The clinical yield of cavotricuspid isthmus (CTI) radiofrequency ablation of atrial flutter (AF) is limited by a high incidence of atrial fibrillation (AFib) in the long term. Among other acknowledged variables, the association of obstructive sleep apnea (OSA) could favor incomplete arrhythmia control in this setting. We assessed the impact of CPAP in reducing the occurrence of AFib after CTI ablation. Methods Consecutive patients with AF who were undergoing CTI ablation were screened for OSA. Relationship of the following variables with the occurrence of AFib during follow-up (12 months) was investigated: CPAP initiation, hypertension, BMI, underlying structural heart disease, left atrial diameter, and AFib documentation prior to ablation. Results We prospectively included 56 patients (mean age: 66 (± 11) years; 12 female patients), of whom 46 (82%) had OSA and 25 (45%) had severe OSA. Twenty-one patients (38%) had AFib during follow-up after CTI ablation. Both freedom from AFib prior to ablation and CPAP initiation in those patients without previously documented AFib at inclusion were associated with a reduction of AFib episodes during follow-up (P = .019 and P = .025, respectively). Inversely, CPAP was not protective from AFib recurrence when this arrhythmia was documented prior to ablation (P = .25). Conclusions OSA is a prevalent condition in patients with AF. Treatment with CPAP is associated with a lower incidence of newly diagnosed AFib after CTI ablation. Screening for OSA in patients with AF appears to be a reasonable clinical strategy.

The association between subclinical cardiovascular disease and subsequent development of erectile dysfunction (ED) remains poorly described.Among multiple subclinical atherosclerosis and vascular dysfunction measurements, coronary artery calcium (CAC) score best predicts ED.After excluding participants taking ED medications at baseline, we studied 1862 men age 45 to 84 years free of known cardiovascular disease from the Multi-Ethnic Study of Atherosclerosis (MESA) with comprehensive baseline subclinical vascular disease phenotyping and ED status assessed at MESA visit 5 (9.4 ± 0.5 years after baseline) using a standardized question on ED symptoms. Multivariable logistic regression was used to assess the associations between baseline measures of vascular disease (atherosclerosis domain: CAC, carotid intima-media thickness, carotid plaque, ankle-brachial index; vascular stiffness/function domain: aortic stiffness, carotid stiffness, brachial flow-mediated dilation) and ED symptoms at follow-up.Mean baseline age was 59.5 ± 9 years, and 839 participants (45%) reported ED symptoms at follow-up. Compared with symptom-free individuals, participants with ED had higher baseline prevalence of CAC score >100 (36.4% vs 17.2%), carotid intima-media thickness Z score >75th percentile (35.3% vs 16.6%), carotid plaque score ≥2 (39% vs 21.1%), carotid distensibility 100 (odds ratio: 1.43, 95% confidence interval: 1.09-1.88) and carotid plaque score ≥2 (odds ratio: 1.33, 95% confidence interval: 1.02-1.73) were significantly associated with ED.Subclinical vascular disease is common in men who later self-report ED. Early detection of subclinical atherosclerosis, particularly advanced CAC and carotid plaque, may provide opportunities for predicting the onset of subsequent vascular ED.

Despite advances in the treatment of heart failure, mortality, the number of readmissions, and their associated health care costs are very high. Heart failure care models inspired by the chronic care model, also known as heart failure programs or heart failure units, have shown clinical benefits in high-risk patients. However, while traditional heart failure units have focused on patients detected in the outpatient phase, the increasing pressure from hospital admissions is shifting the focus of interest toward multidisciplinary programs that concentrate on transitions of care, particularly between the acute phase and the postdischarge phase. These new integrated care models for heart failure revolve around interventions at the time of transitions of care. They are multidisciplinary and patient-centered, designed to ensure continuity of care, and have been demonstrated to reduce potentially avoidable hospital admissions. Key components of these models are early intervention during the inpatient phase, discharge planning, early postdischarge review and structured follow-up, advanced transition planning, and the involvement of physicians and nurses specialized in heart failure. It is hoped that such models will be progressively implemented across the country.

Estimating cardiovascular disease (CVD) risk is necessary for determining the potential net benefit of primary prevention pharmacotherapy. Risk estimation relying exclusively on traditional CVD risk factors may misclassify risk, resulting in both undertreatment and overtreatment. Coronary artery calcium (CAC) scoring personalizes risk prediction through direct visualization of calcified coronary atherosclerotic plaques and provides improved accuracy for coronary heart disease (CHD) or CVD risk estimation. In this review, we discuss the most recent studies on CAC, which unlike historical studies, focus sharply on clinical application. We describe the MESA CHD risk calculator, a recently developed CAC-based 10-year CHD risk estimator, which can help guide preventive therapy allocation by better identifying both high- and low-risk individuals. In closing, we discuss calcium density, regional distribution of CAC, and extra-coronary calcification, which represent the future of CAC and CVD risk assessment research and may lead to further improvements in risk prediction.

Heart failure (HF) is one of the diseases with greater healthcare expenditure. However, little is known about the cost of HF at a population level. Hence, our aim was to study the population-level distribution and predictors of healthcare expenditure in patients with HF.This was a population-based longitudinal study including all prevalent HF cases in Catalonia (Spain) on 31 December 2012 (n = 88 195). We evaluated 1-year healthcare resource use and expenditure using the Health Department (CatSalut) surveillance system that collects detailed information on healthcare usage for the entire population. Mean age was 77.4 (12) years; 55% were women. One-year mortality rate was 14%. All-cause emergency department visits and unplanned hospitalizations were required at least once in 53.4% and 30.8% of patients, respectively. During 2013, a total of €536.2 million were spent in the care of HF patients (7.1% of the total healthcare budget). The main source of expenditure was hospitalization (39% of the total) whereas outpatient care represented 20% of the total expenditure. In the general population, outpatient care and hospitalization were the main expenses. In multivariate analysis, younger age, higher presence of co-morbidities, and a recent HF or all-cause hospitalization were independently associated with higher healthcare expenditure.In Catalonia, a large portion of the annual healthcare budget is devoted to HF patients. Unplanned hospitalization represents the main source of healthcare-related expenditure. The knowledge of how expenditure is distributed in a non-selected HF population might allow health providers to plan the distribution of resources in patients with HF.

Vascular erectile dysfunction is a powerful marker of increased cardiovascular risk. However, current guidelines lack specific recommendations on the role that the evaluation of vascular erectile dysfunction should play in cardiovascular risk assessment, as well on the risk stratification strategy that men with vascular erectile dysfunction should undergo. In the last 3 years, erectile dysfunction experts have made a call for more specific guidance and have proposed the selective use of several prognostic tests for further cardiovascular risk assessment in these patients. Among them, stress testing has been prioritized, whereas other tests are considered second-line tools. In this review, we provide additional perspective from the viewpoint of the preventive cardiologist. We discuss the limitations of current risk scores and the potential interplay between erectile dysfunction assessment and the use of personalized prognostic tools, such as the coronary artery calcium score, in the cardiovascular risk stratification and management of men with vascular erectile dysfunction. Finally, we present an algorithm for primary care physicians, urologists, and cardiologists to aid clinical decision-making.

Background Awareness represents a major modulator for the uptake of preventive measures and healthy life-style choices. Women underestimate the role of cardiovascular diseases as causes of mortality, yet little information is available about their subjective risk awareness. Methods The Berlin Female Risk Evaluation (BEFRI) study included a randomized urban female sample aged 25–74 years, in which 1,066 women completed standardized questionnaires and attended an extensive clinical examination. Subjective estimation was measured by a 3-point Likert scale question asking about subjective perception of absolute cardiovascular risk with a 10 year outlook to be matched to the cardiovascular risk estimate according to the Framingham score for women. Results An expected linear increase with age was observed for hypertension, hyperlipidemia, obesity, and vascular compliance measured by pulse pressure. Knowledge about optimal values of selected cardiovascular risk factor indicators increased with age, but not the perception of the importance of age itself. Only 41.35% of all the participants correctly classified their own cardiovascular risk, while 48.65% underestimated it, and age resulted as the most significant predictor for this subjective underestimation (OR = 3.5 for age >50 years compared to

In this issue, Navarese and colleagues' meta-analysis provides important preliminary information on clinical outcomes of PCSK9 inhibitors as the U.S. Food and Drug Administration considers approval...

Precise risk stratification of atherosclerotic cardiovascular disease guides best management and therefore is a public health priority. In addition to risk estimation using traditional risk factors, tools such as coronary artery calcium, high-sensitivity C-reactive protein, ankle-brachial index and carotid imaging, and clinical features such as family history of premature coronary heart disease may offer opportunities for a more personalized risk assessment. In this review, we discuss the strengths and limitations of each of these tools, focusing on the evidence provided by the latest studies relevant to the field. Among them, coronary artery calcium currently stands out as the most powerful tool for cardiovascular risk assessment, as recognized by the 2013 ACC/AHA Risk Assessment Guideline. Recent studies have expanded our knowledge regarding its value for improving the detection of both low and high absolute risk within clinically relevant subgroups, as well as for cost-effectively guiding preventive therapy allocation.

Introduction: Few studies have evaluated the association between type and amount of dietary protein intake and clinically evident cardiovascular disease, with inconsistent findings, and no study has investigated the association between type and amount of dietary protein intake and subclinical coronary atherosclerosis. Hypothesis: We examined the associations of total, animal, and vegetable protein intakes with coronary artery calcium (CAC) in a large population of asymptomatic adults. Methods: We performed a cross-sectional study of 29,034 asymptomatic young and middle-aged adults (mean age 41.6 years; males 80.3%) who are free of clinically evident cancer or cardiovascular disease. All participants underwent a health screening examination including cardiac computed tomography for CAC scoring and completed a food frequency questionnaire at the Kangbuk Samsung Hospital Total Healthcare Centers in Seoul and Suwon, South Korea from March, 2011 to April, 2013. Protein intake and other nutrient intake were adjusted for total energy intake using the residual method. Multivariable-adjusted CAC score ratios and 95% confidence intervals (CIs) were estimated by robust Tobit regression models for natural logarithm (CAC score + 1). Results: The proportion of study participants with detectable CAC (CAC score > 0) was 13.4 %. After adjustment for total energy intake, other nutrient intake, and potential confounding factors, we found an increased prevalence of CAC with higher animal protein intake, but not with total and vegetable protein intakes. In multivariable-adjusted models, CAC ratios (95% CIs) comparing the highest with the lowest quintiles were 1.82 (1.09-3.04; P for trend = 0.01) for animal protein intake, 1.25 (0.87-1.81; P for trend = 0.13) for vegetable protein intake, and 1.19 (0.74-1.93; P for trend = 0.59) for total protein intake. Conclusion: High animal protein intake, but not total or vegetable protein, was associated with an increased prevalence of subclinical coronary atherosclerosis and with a greater degree of coronary calcification.

Introduction: The role of pulse wave velocity (PWV) in assessing cardiovascular disease (CVD) risk in asymptomatic non-elderly adults is unclear. PWV assessment, however, is readily available, non-invasive, cheap, and does not involve radiation exposure. Hypothesis: The aim of our study was to evaluate the hypothesis that brachial-ankle PWV was associated with coronary artery calcium (CAC) in a large sample of young and middle-aged asymptomatic adults, and that PWV increases the predictive value of traditional CVD risk factors for predicting the presence of CAC. Methods: Cross-sectional study of 15,009 asymptomatic men and women without a history of cardiovascular disease who underwent a health screening program that included both PWV and CAC measurements. Brachial-ankle PWV was obtained from bilateral brachial and posterior tibial artery pressure waveforms using the oscillometric method. Robust tobit regression was used to assess the association between PWV and natural log(CAC+1) and logistic regression was used to model the presence of detectable CAC (CAC>0) and CAC>100 adjusting for multiple CVD risk factors. Measures of calibration and discrimination were calculated to test the incremental value of adding PWV to traditional risk factors in predicting prevalent CAC. Results: The mean age of the study participants was 41.6 years (SD 7.2) and 83% (12,452) were men. Subjects with higher PWV had generally less favorable CVD risk profiles. The multivariable-adjusted CAC score ratios (95% confidence interval) comparing quintiles 2 - 5 of PWV to the first quintile were 1.21 (0.78, 1.86), 1.54 (1.01, 2.33), 1.98 (1.30, 3.01), and 2.83 (1.84, 4.37), respectively (P trend 100 were consistent with the results for CAC ratios. The addition of PWV to traditional risk factors significantly improved the discrimination and calibration of models for predicting the prevalence of detectable CAC (net reclassification index [NRI] for predicting detectable CAC and CAC score > 100 of 0.167 and 0.252, respectively; both p Conclusions: In this large sample of young and middle-aged asymptomatic adults, brachial-ankle PWV was independently associated with the presence and the extent of CAC. PWV measurements improve the prediction of detectable CAC compared to traditional CVD risk factors and may help identify young and middle-age subjects with increased risk of subclinical disease.

Objective: Nonalcoholic fatty liver disease (NAFLD) is associated with insulin resistance (IR) and with other metabolic abnormalities, but the association of NAFLD with the risk of clinical cardiovascular disease (CVD) is controversial. Furthermore, the risk associated with the combination of NAFLD and IR has not been evaluated in prospective studies. The aim of this study was to evaluate the association of NAFLD with or without IR on the incidence of coronary heart disease (CHD) and stroke. Methods: We performed a cohort study in 166,126 adults without CVD at baseline who underwent a health checkup exam during 2008 - 2011 and were followed-up through December 31, 2012 (average follow-up of 3.2 years). NAFLD was defined as hepatic steatosis on ultrasonography in the absence of excessive alcohol use or other identifiable causes. IR was defined as a homeostasis model assessment of IR (HOMA-IR) value ≥ 2.5. Incident hospitalizations for CHD events and strokes were ascertained through data linkage with the Korean Health Insurance Review and Assessment Service (HIRA) database. Results: At baseline, the prevalence of NAFLD and of IR were 25.1 and 6.3%, respectively. During follow-up, 831 participants developed CHD and 582 subjects developed stroke. After adjusting for age, sex, center, year of screening exam, BMI, smoking, alcohol intake, physical activity, family history of CVD, and education, the hazard ratios (95 % confidence intervals) for CHD comparing NAFLD without IR, IR without NAFLD, and NAFLD with IR vs. no NAFLD without IR were 1.07 (0.91 - 1.27), 1.19 (0.74 - 1.91) and 1.55 (1.18 - 2.03), respectively. The corresponding hazard ratios for stroke were 0.93 (0.75 - 1.16), 1.40 (0.83 - 2.35) and 1.82 (1.32 - 2.52), respectively. The P-values for the interaction of NAFLD and IR for CHD and stroke were 0.48 and 0.28, respectively. These associations did not differ by clinically relevant subgroups. Conclusions: The combination of NAFLD and IR was associated with an increased incidence of CHD and of stroke, but this was not observed in those with either NAFLD or IR alone. The combination of NAFLD and IR may identify individuals at high cardiometabolic risk who may need to receive more intensive preventive intervention.

A20 ms increase in the interval between cavo-tricuspid isthmus (CTI) double potentials during incremental pacing (IP) is a highly specific marker differentiating functional from complete CTI block during typical flutter (AFL) ablation. Long-term effects of IP remain unclear. We aimed to assess the impact of IP in reducing AFL recurrences after CTI ablation.One hundred and thirty-four patients (age 67 ± 13 years, 78% males) undergoing successful CTI ablation were included and divided into 2 groups: Group 1 (n = 68), in which ablation was performed before the IP maneuver was incorporated, with CTI block confirmed by at least 1 non-local and 1 local electrogram-based previously established criteria; and Group 2 (n = 66), in which IP maneuver was used to confirm complete CTI block.No intergroup differences were noted in baseline characteristics, ablation settings and fluoroscopy/radiofrequency times. Long-term AFL recurrences were observed in 14 out of 134 patients (10.4%), and were more common in Group 1 (19%, vs 1.5% among Group 2 patients, p0,001). Despite a longer follow-up period among the former group (1603 ± 734 vs. 964 ± 289 days, respectively), the adjusted AFL recurrence rate was still higher among Group 1 patients (4.3%/year vs. 0.6%/year, p0,001). Cox-regression analysis confirmed inclusion in Group 1 as the only predictor of AFL recurrences (HR = 8.2, CI 1.04-64.7, p = 0.046).The addition of the IP maneuver for the diagnosis of complete CTI block reduces AFL long-term recurrences after ablation.

The clinical yield of cavotricuspid isthmus (CTI) radiofrequency ablation of atrial flutter (AF) is limited by a high incidence of atrial fibrillation (AFib) in the long term. Among other acknowledged variables, the association of obstructive sleep apnea (OSA) could favor incomplete arrhythmia control in this setting. We assessed the impact of CPAP in reducing the occurrence of AFib after CTI ablation.Consecutive patients with AF who were undergoing CTI ablation were screened for OSA. Relationship of the following variables with the occurrence of AFib during follow-up (12 months) was investigated: CPAP initiation, hypertension, BMI, underlying structural heart disease, left atrial diameter, and AFib documentation prior to ablation.We prospectively included 56 patients (mean age: 66 (± 11) years; 12 female patients), of whom 46 (82%) had OSA and 25 (45%) had severe OSA. Twenty-one patients (38%) had AFib during follow-up after CTI ablation. Both freedom from AFib prior to ablation and CPAP initiation in those patients without previously documented AFib at inclusion were associated with a reduction of AFib episodes during follow-up (P = .019 and P = .025, respectively). Inversely, CPAP was not protective from AFib recurrence when this arrhythmia was documented prior to ablation (P = .25).OSA is a prevalent condition in patients with AF. Treatment with CPAP is associated with a lower incidence of newly diagnosed AFib after CTI ablation. Screening for OSA in patients with AF appears to be a reasonable clinical strategy.

Antidepressants; Comorbidity; Drug utilization study; Europe Antidepresivos; Comorbilidad; Estudio de utilización de medicamentos; Europa Antidepressius; Comorbiditat; Estudi d'utilització de medicaments; Europa Background We aimed to describe patterns of use and characteristics of 10 commonly used antidepressants for the period 2009–2014 in Denmark, Germany, Spain, and Sweden. Methods Adult initiators from 2009 to 2014 of each study antidepressant were identified in four countries using five data sources: the Danish National registers, GePaRD (Germany), EpiChron (Aragon, Spain), SIDIAP (Catalonia, Spain), and the Swedish National Registers. The study included 10 study antidepressants: citalopram, escitalopram, fluoxetine, paroxetine, sertraline, duloxetine, venlafaxine, amitriptyline, mirtazapine, and agomelatine. Results Citalopram was the most prescribed study antidepressant, followed by mirtazapine. Paroxetine and agomelatine were the least prescribed antidepressants. Mirtazapine was widely used among older antidepressant initiators with higher percentages of comorbidities at baseline, and fluoxetine was used among young patients. Citalopram and amitriptyline had the lowest percentage of multiple antidepressant use in the 12 months prior to the current treatment episode, while agomelatine, duloxetine, and venlafaxine had the highest percentage of multiple antidepressant use in the year prior to the current treatment episode. Limitations The most important limitations are exposure information based on filled prescriptions, focus on antidepressant initiators only, lack of information on the indication, and heterogeneity of the type of data across data sources. Conclusions Results of this study including 4.8 million study antidepressant initiators of study antidepressants suggest that citalopram and mirtazapine are the most commonly prescribed antidepressants. Agomelatine and paroxetine were the least used antidepressants in the participating populations. Mirtazapine was the antidepressant most commonly prescribed among older antidepressant initiators with high percentage of comorbidities at baseline, whereas fluoxetine was commonly used among young patients.