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Introduction: Data regarding 10-year survival and adverse cardiovascular events in patients with metabolic syndrome (MET) after coronary artery bypass grafting (CABG) is limited., Methods: We compared 10-year events rates for veterans undergoing isolated CABG (January 1, 2005, to December 31, 2014, follow-up October 31, 2019) stratified by presence of metabolic syndrome (MET+) versus without (MET-). A multivariable weighted Cox model was used to analyze all-cause mortality. Competing risk analysis was used to calculate cumulative event rates for congestive heart failure, myocardial infarction, and cerebrovascular events. The Fine-Gray subhazard model was used to determine adjusted association of MET with myocardial infarction and stroke. Congestive heart failure was modeled as a recurrent-event analysis., Results: Nationally, 9615 adults (median age, 60 years; 98.9% men) underwent isolated coronary artery bypass grafting at 41 centers); among them, 3121 out of 9615 (32.5%) had MET. The prevalence of MET increased from (27.88% in 2005 to 34.02% in 2014; P = .02). MET+ group members were likely younger (median age, 63 vs 64 years; P < .01), White (72% vs 68%), and had more peripheral vascular disease (30% vs 28%; P = .04). Multivessel (72% vs 70%; P = .23) and multiarterial (4% vs 4%; P = .14) grafting was performed equally. With a median follow-up of 6.5 years, survival was similar (P = .26); however, MET was associated with higher risks for myocardial infarction (21% vs 16%; hazard ratio, 1.3; P < .01) and recurrent admissions for congestive heart failure., Conclusions: Patients with metabolic syndrome undergoing coronary artery bypass grafting have higher 10-year cardiovascular event rates., (Published by Elsevier Inc.)

Objectives: We analysed the Veteran Affairs data to evaluate the association of pre-operative glycated haemoglobin (HbA1c) and long-term outcome after isolated coronary artery bypass grafting (CABG)., Methods: Veterans with diabetes mellitus and isolated CABG (2006-2018) were divided into 4 groups (I: HbA1c <6.5%, II: HbA1c 6.5-8, III 8-10% and IV: HbA1c >10%). The relationship of pre-operative HbA1c and long-term survival was evaluated with a multivariable Cox proportional hazards model and reported as hazard ratios (HR). The cumulative incidence of secondary end-points [myocardial infarction (MI) and repeat revascularization (percutaneous intervention)] for each group was modelled as competing events with cause-specific Cox proportional hazards models., Results: Overall, 16 190 patients (mean age 64.9 years, male 98%; insulin dependent 53%) with diabetes mellitus underwent isolated CABG. We observed 19.4%, 45.4%, 27% and 8.2% patients in groups I, II, III and IV, respectively. Patients with HbA1c >10% were the youngest (mean age 60.9 years) and had high rates of Insulin dependence (78%). In patients with HbA1c >10%, improvement in levels was observed in 76%. The median follow-up observed was 5.8 (3.2-8.8) years. Compared to the study mean HbA1c (7.3%), mortality rate increased with HbA1c levels >8%, and especially with pre-operative HbA1c levels >9%. Compared to patients with HbA1c <8%, HbA1c 8-10% and >10% were associated with increased MI (HR 1.24 and HR 1.39, respectively) and need for reintervention (HR 1.20 and HR 1.24, respectively)., Conclusions: In patients undergoing CABG, pre-operative HbA1c >8% is associated with the increased risk of mortality and adverse cardiac events., (Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery 2021. This work is written by US Government employees and is in the public domain in the US.)

Cardiovascular (CV) risk factors like diabetes and hypertension are poorly controlled in both rural and urban India. This study was designed to identify the reasons for suboptimal control in a semiurban population in India. A total of 70 participants from the Study to Expand Heart Associated Treatments (SEHAT) trial, conducted in West Bengal, India. We qualitatively examined perspectives regarding CV risk factor control using focus group discussions based on the theory of reasoned action. Qualitative content analysis was used to analyze prevailing themes. Participants demonstrated a generalized knowledge of healthy lifestyle practices but lacked insight into disease-specific prevention methods. We further noticed significant gaps in the translation of existing knowledge into behavior. While personal and systemic barriers exist, factors like high patient motivation and a deep sense of trust in providers can potentially be harnessed to improve risk factor control in the community. We identified key facilitators and barriers to CV risk factor control in the community using a knowledge attitude behavior approach. Our findings provide direction for the development of community-based CV risk reduction models., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 Journal of Family Medicine and Primary Care.)

Background: Eighty percent of premature mortality from cardiovascular disease occurs in low- and middle-income countries. Hypertension, diabetes, and smoking are the top risk factors causing this disease burden., Objectives: The study aimed to test the hypothesis that utilizing community health workers (CHWs) to manage hypertension, diabetes and smoking in an integrated manner would lead to improved control of these conditions., Methods: This was a 2-year cluster (n = 12) randomized controlled trial of 3,556 adults (35 to 70 years of age) in a single town in India, who were screened at home for hypertension, diabetes, and smoking. Of these adults, 1,242 (35%) had at least 1 risk factor (hypertension = 650, diabetes = 317, smoking = 500) and were enrolled in the study. The intervention group had behavioral change communication through regular home visits from community health workers. The control group received usual care in the community. The primary outcomes were changes in systolic blood pressure, fasting blood glucose, and average number of cigarettes/bidis smoked daily among individuals with respective risk factors., Results: The mean ± SD change in systolic blood pressure at 2 years was -12.2 ± 19.5 mm Hg in the intervention group as compared with -6.4 ± 26.1 mm Hg in the control group, resulting in an adjusted difference of -8.9 mm Hg (95% confidence interval [CI]: -3.5 to -14.4 mm Hg; p = 0.001). The change in fasting blood glucose was -43.0 ± 83.5 mg/dl in the intervention group and -16.3 ± 77.2 mg/dl in the control group, leading to an adjusted difference of -21.3 mg/dl (95% CI: 18.4 to -61 mg/dl; p = 0.29). The change in mean number of cigarettes/bidis smoked was nonsignificant at +0.2 cigarettes/bidis (95% CI: 5.6 to -5.2 cigarettes/bidis; p = 0.93)., Conclusions: A population-based strategy of integrated risk factor management through community health workers led to improved systolic blood pressure in hypertension, an inconclusive effect on fasting blood glucose in diabetes, and no demonstrable effect on smoking. (Study of a Community-Based Approach to Control Cardiovascular Risk Factors in India [SEHAT]; NCT02115711)., (Copyright © 2019 World Heart Federation (Geneva). Published by Elsevier B.V. All rights reserved.)

Background: Nearly 275 million individuals in India consume tobacco every day, with more than 1 million dying annually as a result. Few people in India have access to smoking cessation services, an essential component of combating tobacco use globally. We hypothesize that a strategy of systematic community health worker (CHW) based counseling that covers eligible people who smoke in a geographical area, combined with text messaging support, will result in improved quit rates., Methods: The study is a cluster randomized controlled trial that will be conducted at 2 sites in India. Sixteen clusters will be randomized into either an intervention or control arm. A total of 560 smokers between the age of 18 and 70 will be recruited from their home through CHWs. Smokers at all stages of change will be offered the intervention, which is based on the transtheoretical model of change., Results: Pre-contemplative participants will be offered health education and motivational interviewing through CHWs. They will also be offered a low frequency form of text messaging, focused on health education and the benefits of quitting. Participants who are actively contemplating quitting smoking will be offered a more intensive intervention, with more frequent visits by CHWs and more intensive text messaging support. Contemplative participants will be encouraged to set a quit date, and all participants will be assessed periodically for stage of change to provide the appropriate intervention. Participants who set a quit date will be encouraged to use NRT to help with quitting. Control group participants are provided with brief smoking cessation advice only, at the start of the trial. The primary outcome will be self-reported abstinence for the past 14 days, biochemically verified by exhaled CO levels (cut-off 10 ppm) assessed at the end of 1 year of the intervention., Conclusions: We will test whether a CHW-based intervention that incorporates motivational interviewing, text messaging and supportive counseling can prove effective in systematically helping smokers quit., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: The Wilkins score and commissural calcification scores predict outcomes after percutaneous balloon mitral valvuloplasty. However, many cardiologists are inadequately trained in their application-both in the United States where the incidence of rheumatic heart disease has fallen and in rheumatic heart disease endemic countries where training infrastructure is weak., Objectives: This study sought to develop a computer-based educational module teaching 2 scoring systems for rheumatic mitral stenosis and to validate the module among cardiology fellows in the United States and Uganda., Methods: We developed a module organized into 3 sets of 10 echocardiograms each. The module was completed by 13 cardiology fellows from 2 academic centers in the United States and 1 in Uganda. Subject answers were compared with a score assigned by 2 experts in echocardiography. The primary outcome was change in subjects' accuracy from set 1 to set 3, measured by mean absolute deviation from expert scores. Secondary outcomes included change in interoperator variability and individual subject bias from set 1 to set 3., Results: The mean absolute deviations from expert scores in sets 1 and 3 were 2.09 and 1.82 for the Wilkins score (possible score range 0 to 16) and 1.13 and 0.94 for the commissural calcification score (possible score range 0 to 4). The change from set 1 to set 3 was statistically significant only for 1 of the Wilkins component scores (leaflet calcification, p < 0.001.) No change was seen in the interoperator variability. Individual subject bias in assigning the total Wilkins score was reduced from set 1 to set 3., Conclusions: Use of this module has the potential to enhance the training of cardiologists in the echocardiographic assessment of mitral stenosis. Modified versions of this module or similar ones should be tested in targeted populations of cardiology trainees with the most exposure to mitral stenosis interventions., (Copyright © 2018 World Heart Federation (Geneva). Published by Elsevier B.V. All rights reserved.)

Background: Cardiovascular disease is the leading cause of mortality in India. Since it is largely driven by risk factors such as hypertension, diabetes and smoking, it is important to study the treatment cascade for these conditions and identify areas for improvement., Methods: This is a cross-sectional study from Project SEHAT (Study to Enhance Heart Associated Treatments), an ongoing cluster randomised controlled trial testing the hypothesis that a community health worker-led intervention can improve the control of cardiovascular risk factors in a community in West Bengal, India. For the baseline data, 3556 adults, between the ages of 35 and 70, were screened for hypertension, diabetes and smoking. For hypertension and diabetes, an elevated reading was confirmed on a repeat visit., Results: 18.3% (n=650), 9.0% (n=317) and 14.1% (n=500) of adults were diagnosed with hypertension, diabetes and smoking, respectively. Overall, 35.0% (n=1242) adults had at least one of the three risk factors. 55.1% (n=358) of participants with hypertension and 40.4% (n=128) of participants with diabetes were unaware of their respective condition. 36.6% (n=238) of those with hypertension and 58.0% (n=184) of diabetics were on treatment. 8.2% (n=53) hypertensives were controlled (blood pressure <140/90 mm Hg) while 13.6% (n=43) diabetics were controlled (defined as fasting blood sugar <126 mg/dL). Less than 1% diabetics were on insulin, and average number of medications for a patient with hypertension was 1.2., Conclusions: In our population in semiurban India, one in three adults have a major cardiovascular risk factor, with low control rates. There is a large burden of undiagnosed cardiovascular risk factors and a large gap between treatment and control, which may be explained by lack of treatment intensification., Competing Interests: Competing interests: None declared.

Community health workers (CHW) may be effective in tackling the burden of cardiovascular diseases in low- and middle-income countries (LMIC). This review examines whether CHWs can improve the identification and control of cardiovascular risk factors in LMIC. We searched for studies that used CHW as a basis for cardiovascular risk factor management. Our search yielded 11 articles that targeted cardiovascular risk factor assessment, hypertension, diabetes, smoking, diet and physical activity. There were 4 randomized controlled trials, 3 quasi-experimental studies, 3 cross-sectional studies, and 1 retrospective analysis. Eight studies reported positive results with CHW being able to effectively screen for cardiovascular risk factors, decrease systolic blood pressure, decrease fasting blood glucose, increase quit rates of smoking, decrease weight, and improve diet and physical activity. Our review demonstrates that CHW may be effective in helping tackle the burden of cardiovascular disease in LMIC., (Copyright © 2016 World Heart Federation (Geneva). Published by Elsevier B.V. All rights reserved.)

Cardiac rehabilitation (CR) has proven morbidity and mortality benefits in cardiovascular disease, which directly correlates with exercise performance achieved. Many patients in CR exercise at sub-optimal levels, without obvious limitations. Occult lower-extremity peripheral artery disease (PAD) may be a determinant of diminished exercise capacity and reduced benefit obtained from traditional CR. In this prospective study of 150 consecutive patients enrolled in Phase II CR, we describe the prevalence of PAD, the utility of externally validated screening questionnaires, and the observed impact on CR outcomes. Abnormal ankle-brachial indices (ABI) (< 0.9 and >1.4) were observed in 19% of those studied. The Edinburgh Claudication Questionnaire was insensitive for detecting PAD by low ABI in this population, and the Walking Impairment Questionnaire and a modified Gardner protocol demonstrated a lack of typical symptoms with low levels of activity. Importantly, at completion of traditional CR, exercise improvement measured in metabolic equivalents (METs) was worse in those with a low ABI compared to those with a normal ABI (+1.39 vs +2.41 METs, p = 0.002). In conclusion, PAD is common in patients in Phase II CR and often clinically occult. Screening based on standard questionnaires appears insensitive in this population, suggesting a need for a broad-based screening strategy with ABI measurements. In this study, undiagnosed PAD significantly attenuated improvements in exercise performance, which potentially has bearings on future clinical events., (© The Author(s) 2016.)

The importance of coronary collateral circulation in relation to the left ventricular function, aneurysm formation and size was investigated in 100 patients with previous 'Q' wave myocardial infarction who underwent coronary angiography. Aneurysms were present in 20% of patients. The majority of these (80%) patients had severe or total occlusion of the left anterior descending artery. Thirty four percent of patients without aneurysm had significant collaterals whereas 25% of patients with aneurysms had collaterals (P > 0.05). However, the size of the aneurysm was smaller when adequate collateral circulation was present (Collateral Index 2 or above). The incidence of hypertension and diabetes was similar in both groups. Collateral circulation was more frequently seen in the anterior (60%) as compared to inferior myocardial infarction (40%), but Collateral Index was higher in right coronary artery disease. The number of patients with an elevated left ventricular end-diastolic pressure (> 12) or poor ejection fraction was similar in the two groups with and without collaterals. Thus, there was no beneficial effect of collateral circulation on left ventricular function. The incidence of aneurysm was not significantly lower, although the size of the aneurysm was significantly smaller in the presence of collateral circulation.