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The global obesity epidemic is well established, with increases in obesity prevalence for most countries since the 1980s. Obesity contributes directly to incident cardiovascular risk factors, including dyslipidemia, type 2 diabetes, hypertension, and sleep disorders. Obesity also leads to the development of cardiovascular disease and cardiovascular disease mortality independently of other cardiovascular risk factors. More recent data highlight abdominal obesity, as determined by waist circumference, as a cardiovascular disease risk marker that is independent of body mass index. There have also been significant advances in imaging modalities for characterizing body composition, including visceral adiposity. Studies that quantify fat depots, including ectopic fat, support excess visceral adiposity as an independent indicator of poor cardiovascular outcomes. Lifestyle modification and subsequent weight loss improve both metabolic syndrome and associated systemic inflammation and endothelial dysfunction. However, clinical trials of medical weight loss have not demonstrated a reduction in coronary artery disease rates. In contrast, prospective studies comparing patients undergoing bariatric surgery with nonsurgical patients with obesity have shown reduced coronary artery disease risk with surgery. In this statement, we summarize the impact of obesity on the diagnosis, clinical management, and outcomes of atherosclerotic cardiovascular disease, heart failure, and arrhythmias, especially sudden cardiac death and atrial fibrillation. In particular, we examine the influence of obesity on noninvasive and invasive diagnostic procedures for coronary artery disease. Moreover, we review the impact of obesity on cardiac function and outcomes related to heart failure with reduced and preserved ejection fraction. Finally, we describe the effects of lifestyle and surgical weight loss interventions on outcomes related to coronary artery disease, heart failure, and atrial fibrillation. [ABSTRACT FROM AUTHOR]

Obesity is associated with the development and progression of multiple cardiovascular risk factors, such as hypertension, dyslipidemia, and type 2 diabetes mellitus, and is an important contributor to the global burden of atherosclerotic cardiovascular disease (CVD). Guidelines suggest that clinicians provide lifestyle counseling and promote lifestyle modifications before considering weight-loss surgery. However, despite lifestyle modifications and increased physical activity, most patients with obesity will not lose significant weight or will experience weight regain. Weight-loss pharmacotherapy added to lifestyle modification has long been perceived as a bridge between lifestyle modifications alone and weight-loss surgery. However, since its inception, weight-loss pharmacotherapy has been plagued by variable efficacy and concern about cardiovascular safety. Following requirements from regulatory authorities, efficacy and cardiovascular safety trials have been conducted for the currently available weight-loss pharmacotherapeutic agents. Overall, these trials have shown that weight-loss pharmacotherapy is only modestly efficient for the inducement of weight loss. Recent trials have also demonstrated the cardiovascular safety of some of these agents. We review these trials with a focus on the clinical impact of these weight-loss pharmacotherapeutic agents in patients with atherosclerotic CVD. [ABSTRACT FROM AUTHOR]

Targeting metabolic determinants of exercise performance with pharmacological agents that would mimic/potentiate the effects of exercise represents an attractive clinical alternative to counterbalance the poor exercise capacity in patients with type 2 diabetes mellitus (T2DM). We examined the effect of 1-yr treatment with the insulin sensitizer peroxisome proliferator-activated receptor (PPAR)γ agonist rosiglitazone on aerobic exercise capacity and body fat composition/distribution in men with T2DM and stable coronary artery disease (CAD). One-hundred four men (age: 64 ± 7 yr; body mass index: 30.0 ± 4.4 kg/m2) with T2DM and CAD were randomized to receive rosiglitazone or placebo for 1 yr. Aerobic exercise capacity (exercise duration) was assessed with a maximal treadmill test, and body composition/distribution were assessed by dual-energy X-ray absorptiometry/computed tomography scans. At 1 yr, patients with T2DM under PPARγ agonist treatment showed a reduction in aerobic exercise capacity compared with the control group (exercise duration change, -31 ± 8 versus 7 ± 11 s, P = 0.009). Significant increases in body fat mass (3.1 ± 0.4 kg, 12%), abdominal and mid-thigh subcutaneous adipose tissue (AT) levels, and mid-thigh skeletal muscle fat were found (all P < 0.01), whereas no effect on visceral AT levels was observed (P > 0.05) under treatment. Subcutaneous fat mass gained under PPARγ agonist was the strongest predictor of the worsening in aerobic exercise capacity (P > 0.0001); no association was found with skeletal muscle fat infiltration nor visceral AT. Treatment with the insulin sensitizer PPARγ agonist rosiglitazone in patients with T2DM and CAD is associated with a worsening in aerobic exercise capacity, which seems to be mainly attributable to weight gain and subcutaneous fat mass expansion. [ABSTRACT FROM AUTHOR]

The prevalence of obesity has increased globally over the last 2 decades. Although the body mass index has been a convenient and simple index of obesity at the population level, studies have shown that obesity defined by body mass index alone is a remarkably heterogeneous condition with varying cardiovascular and metabolic manifestations across individuals. Adipose tissue is an exquisitely active metabolic organ engaged in cross-talk between various systems; perturbation of adipose tissue results in a pathological response to positive caloric balance in susceptible individuals that directly and indirectly contributes to cardiovascular and metabolic disease. Inadequate subcutaneous adipose tissue expansion in the face of dietary triglycerides leads to visceral and ectopic fat deposition, inflammatory/adipokine dysregulation, and insulin resistance. Conversely, preferential fat storage in the lower body depot may act as a metabolic buffer and protect other tissues from lipotoxicity caused by lipid overflow and ectopic fat. Translational, epidemiological, and clinical studies over the past 30 years have clearly demonstrated a strong link between visceral and ectopic fat and the development of a clinical syndrome characterized by atherogenic dyslipidemia, hyperinsulinemia/glucose intolerance, hypertension, atherosclerosis, and adverse cardiac remodeling/heart failure. This relationship is even more nuanced when clinical entities such as metabolically healthy obesity phenotype and the obesity paradox are considered. Although it is clear that the accumulation of visceral/ectopic fat is a major contributor to cardiovascular and metabolic risk above and beyond the body mass index, implementation of fat distribution assessment into clinical practice remains a challenge. Anthropometric indexes of obesity are easily implemented, but newer imaging-based methods offer improved sensitivity and specificity for measuring specific depots. Lifestyle, pharmacological, and surgical interventions allow a multidisciplinary approach to overweight/obesity that may improve outcomes and align with a public health message to combat the growing epidemic of obesity worldwide and to build healthier lives free of cardiovascular diseases. [ABSTRACT FROM AUTHOR]

Background Although no receptor has yet been identified, changes in circulating levels of the adipokine designated as Omentin have been demonstrated in obesity and related comorbidities such as cardiovascular disease, insulin resistance, metabolic syndrome and chronic inflammation. Methods Changes in Omentin levels at 1 and 5 days and 6 and 12 months in response to biliopancreatic diversion with duodenal switch bariatric surgery were evaluated, specifically to investigate if changes preceded gain of insulin sensitivity Results Pre-operative plasma Omentin was not different between men (n = 18) vs women (n = 48), or diabetic status but correlated with body mass index (BMI). Altogether, Omentin increased as early as 24-h post-surgery, with changes maintained up to 1-year. Fifty-nine percent of subjects increased Omentin >10% by 24-H following surgery (OmentinINC p < 0.0001), while 18% of subjects decreased (OmentinDEC p < 0.0001), with changes maintained throughout one-year. These two groups had comparable age, sex distribution, diabetes, BMI, waist circumference and fat mass, however OmentinDEC had elevated levels of cardiovascular risk markers; homocysteine (p = 0.019), NT-proBNP (p = 0.006) and total bilirubin (p = 0.0001) while red blood cell (RBC) count was lower (p = 0.0005) over the one-year period. Omentin levels at 1-DAY also correlated with immune parameters (white blood cell count, % neutrophil, % monocytes, % lymphocytes). Conclusion OmentinDEC at 1 day following surgery may be a marker of cardiovascular "at-risk"group before weight loss or insulin sensitivity restoration. [ABSTRACT FROM AUTHOR]

Purpose: Obesity is associated with left ventricular diastolic dysfunction and altered heart rate variability, as well as pulmonary dysfunction. The relationship between asthma and cardiac dysfunction in severely obese subjects is unknown, although it has been hypothesized that cardiac dysfunction may contribute to increase airway hyper-responsiveness (AHR). This study aimed to determine if AHR is associated with left ventricular diastolic dysfunction and heart rate variability in severely obese subjects. Methods: Sixty-one subjects with severe obesity (BMI ≥35 kg/m² with comorbidities) completed this study. All subjects completed respiratory questionnaires, spirometry, lung volume measurements, methacholine inhalation test, 24hour Holter monitoring and a complete echocardiography evaluation. Blood samples were obtained for measurement of metabolic markers. Subjects with AHR, defined by a provocative concentration of methacholine inducing a 20% fall in FEV1 (PC20) <8 mg/ml, were compared with those with no AHR (PC20 ≥8 mg/ml). Results: According to these criteria, 32 subjects had AHR and 29 had no AHR(mean PC201.70 mg/ml and 15.3 mg/ml respectively, p<0.001). The groups were similar for anthropometric data and comorbidities. Fasting glucose, Hb1Ac, total cholesterol, LDL, triglycerides, Apo-B, C-reactive protein (CRP) and pro-BNP levels were also comparable between groups (p>0.05). CRP level correlated with PC20 (AHR, r=0.38, p=0.03). Indices of heart rate variability and overall cardiac function were similar in subjects with or without AHR but grade 2 left ventricular diastolic dysfunction was more prevalent in subjects with AHR (p=0.037). Conclusions: Altered cardiac function, dysglycemia and dyslipidemia do not seem to be significantly associated with AHR in severely obese subjects in contrast to systemic inflammation. [ABSTRACT FROM AUTHOR]

Objectives: Obesity is rising globally and severe obesity (SO) [body mass index (BMI) = 40 kg/m2 or = 35 kg/m2 with co-morbidity] is growing at a much faster rate. Amongst the Inuit, evolution of SO remains unknown. We investigated whether the level of SO changed and whether the cardio-metabolic profile improved or deteriorated in Nunavik Inuit between 1992 and 2004. Methods: SO subjects were selected from two comparable population-based studies. These studies were undertaken in Nunavik (Quebec, Canada), and were performed in two different time frames, separated by 12 years. Physiological (lipid profile, fasting insulin, fasting glucose, and blood pressure) as well as anthropometric data (BMI, waist circumference, and waist to hip ratio) were collected in both studies. Resutls: There was approximately a fourfold increase in the prevalence of SO in comparable age groups. This increase affected both genders between 1992 and 2004. Smoking rates in SO populations have significantly decreased during this period, from 85% to 41% ( P < 0.0001). Overall, there were no statistically significant differences in the cardio-metabolic profile (insulin, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, systolic and diastolic blood pressures, BMI, and waist to hip ratio). There was, however, a significant increase in waist circumference ( P < 0.001), especially in women ( P < 0.01). Type 2 diabetes remained stable, at around 40% in this population. Conclusion: Although the prevalence of SO increased, the cardio-metabolic profile remained stable. Nevertheless, regular monitoring of chronic disease in this population remains crucial. Am. J. Hum. Biol., 2012. © 2012 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To assess the efficacy and safety of rosiglitazone on saphenous vein graft (SVG) atherosclerosis prevention and on modification of the global cardiometabolic risk profile. Methods and results: This was a double-blind, randomized, placebo-controlled, multicenter trial which enrolled 193 post-CABG patients with type 2 diabetes. Atherosclerosis changes in one SVG were assessed with intravascular ultrasound at baseline and at 12 months. Serial cardiometabolic assessments were performed. At baseline, both groups had mean HbA1C <7%, LDL-cholesterol (LDL-C)<2.3mmol/l, HDL-cholesterol (HDL-C)>1.0mmol/l and blood pressure<130/75 mmHg. After 12 months, plaque volume in SVG had increased (median [interquartile range]) by 7.7mm3 (−17.2 to 37.9) in the placebo group and decreased by 0.3mm3 (−19.1 to 22.3) in the rosiglitazone group (P =0.22). Compared to placebo, rosiglitazone treated patients had a higher (mean±SD) body weight (89±15kg vs. 84±15kg, P =0.02) at the end of the study, mostly related to an increment in subcutaneous adipose tissue. Rosiglitazone treated patients also displayed further improvements in glycemic control compared to placebo (HbA1C: 6.4±0.7% vs. 7.0±0.9%, P <0.001) as well as in several cardiometabolic parameters such as lipids (HDL-C: 1.16±0.28mmol/l vs. 1.06±0.23mmol/l, P =0.003), inflammatory profile (C-reactive protein: 0.92mg/l [0.51–1.56] vs. 1.37mg/l [0.79–3.08], P =0.02), and adiponectin levels (11.1μg/ml [8.19–17.9] vs. 4.65μg/ml [3.27–7.15], P <0.001). There was no significant difference in the incidence of serious adverse cardiovascular events. However, more patients in the rosiglitazone group had peripheral oedema (33% vs. 18%, P =0.0019). Conclusion: After a 12-month follow-up, we found no evidence for a statistically significant effect of rosiglitazone on SVG atherosclerosis whereas significant effects on glycemic control and on the cardiometabolic risk profile appeared to be modulated in part by changes in subcutaneous adiposity. [Copyright &y& Elsevier]

Abstract: Purpose: Obesity, physical inactivity and altered estrogen metabolism play an integrated role contributing to the disease risk profiles of postmenopausal women. These same risk factors also affect modulation of the autonomic nervous system (ANS). Methods: We examined 332 postmenopausal, overweight, previously sedentary women (mean±SD; age, 57.6±6.3 years; weight, 84.3±11.9kg; BMI, 31.7±3.7kg/m2) participating in a 6-month, moderate intensity, aerobic exercise training intervention to determine the relationship between heart rate variability (HRV) derived autonomic function and fasting insulin. We analyzed quartiles of change in time and frequency domain indices of ANS activity and changes in insulin for between and within group differences using ANCOVA and Tukey post hoc tests adjusted for age, ethnicity, randomization group, change in fitness, and change in weight. Results: We observed at baseline that insulin was positively correlated with body anthropometry (body weight, r 2 =0.34; BMI, r 2 =0.39; waist circumference, r 2 =0.29; all, P <0.001), and inversely associated with rMSSD (r 2 =−0.12) and SDNN (r 2 =−0.18; all, P <0.01). After the intervention, changes in rMSSD (r 2 =−0.21, P <0.002) and SDNN r 2 −0.19, P <0.0001) were inversely correlated to insulin change. Further ANCOVA analysis revealed that rMSSD and SDNN were both significant (P <0.0001); however, only rMSSD exhibited a step-wise pattern of improvement when quartiles of rMSSD were compared to corresponding insulin reductions: Q1 (referent group, 8.41±3.2 uIU/ml), Q2 (−3.30±−3.2 uIU/ml), Q3 (−5.66±−3.2 uIU/ml; P <0.02), and Q4 (−9.60±−3.2 uIU/ml; P <0.006). Conclusion: Our study shows that changes in autonomic function are associated with changes in insulin and that exercise training may influence this relationship in postmenopausal women. [Copyright &y& Elsevier]

Abstract: Many clinical guidelines recommend aspirin therapy for the prevention of cardiovascular events in individuals with type 2 diabetes. However it is unclear whether the level of evidence in guidelines is derived from studies carried out among individuals with diabetes. Medline and Embase databases were searched to retrieve studies published since 1990, evaluating the effect of aspirin on cardiovascular outcomes in subjects with type 2 diabetes. Four studies corresponded to the inclusion criteria. The three clinical trials retrieved could not prove from a statistical point of view, the benefits of aspirin therapy for subjects with type 2 diabetes. Reduction in cardiac mortality was found only in one observational study. Consequently, these findings suggest that the clinical guidelines have based their recommendations upon the expected benefit previously observed in other high-risk populations. Given the lack of hard evidence and the different well-known platelet physiology encountered in patients with diabetes, use of aspirin as a standard treatment at the highest level of evidence in guidelines for subjects with type 2 diabetes should be revisited. [Copyright &y& Elsevier]

The article discusses the progress made in the prevention, management and treatment of cardiovascular diseases (CVD) in Canada. However, there still remains a wide gap between the real state of health of the population and the management and treatment of CVD patients. Health care professionals are still wondering about the priorities towards which they should manage CVD. They all agree that individual behavior modification is the key to preventing CVD.

Abstract: Background: Several studies have demonstrated persistent reduced exercise capacity in Fontan patients even after surgical intervention. The purpose of this study was to evaluate if the skeletal muscle function of these patients is abnormal, if it correlates with exercise tolerance and if it can be improved by exercise training. Methods: We evaluated the functional capacity of seven patients who underwent Fontan procedure (age:16±5 years, mean±SD) and seven healthy children (19±7 years) paired for age, sex, height and weight. Evaluation included pulmonary evaluation, neuromuscular function and exercise tolerance. Secondly, an 8-week exercise training program was performed by five of these patients. Results: The ergoreflex contribution to absolute diastolic blood pressure was higher (12.5±4.8 vs. 5.6±4.2 mm Hg; p =0.04) in Fontan patients vs. healthy subjects whereas a trend was encountered regarding the ergoreflex contribution to absolute systolic blood pressure (9.0±7.0 vs. 0.4±9.0 mm Hg; p =0.09). Furthermore, time to fatigue of the non-dominant forearm muscles was shorter in Fontan patients vs. healthy subjects (431±290 vs. 847±347 s; p =0.03). Following exercise training, there was a significant reduction of the ergoreflex contribution to absolute values of systolic blood pressure (9.8±0.9 vs. 0.3±2.7 mm Hg; p <0.05). There was an association between muscle strength and V˙O2 peak in Fontan patients (upper limb: r =0.895; p <0.01; lower limb: r =0.838; p <0.05, respectively). Conclusions: Skeletal muscle function in Fontan patients is abnormal which may have an impact in the reduced exercise tolerance encountered in these patients. Exercise training may have beneficial impacts on the skeletal muscle function in this population. [Copyright &y& Elsevier]

Objective: Because a pseudonormal pattern of ventricular filling has never been considered in studies that reported a prevalence of left ventricular diastolic dysfunction (LVDD) between 20 and 40%, our aim was to more completely evaluate the prevalence of LVDD in subjects with diabetes.Research Design and Methods: We studied 46 men with type 2 diabetes who were aged 38-67 years; without evidence of diabetic complications, hypertension, coronary artery disease, congestive heart failure, or thyroid or overt renal disease; and with a maximal treadmill exercise test showing no ischemia. LVDD was evaluated by Doppler echocardiography, which included the use of the Valsalva maneuver and pulmonary venous recordings to unmask a pseudonormal pattern of left ventricular filling.Results: LVDD was found in 28 subjects (60%), of whom 13 (28%) had a pseudonormal pattern of ventricular filling and 15 (32%) had impaired relaxation. Systolic function was normal in all subjects, and there was no correlation between LVDD and indexes of metabolic control.Conclusions: LVDD is much more common than previously reported in subjects with well-controlled type 2 diabetes who are free of clinically detectable heart disease. The high prevalence of this phenomenon in this high-risk population suggests that screening for LVDD in type 2 diabetes should include procedures such as the Valsalva maneuver and pulmonary venous recordings to unmask a pseudonormal pattern of ventricular filling. [ABSTRACT FROM AUTHOR]

Summary Objectives Methods Results Conclusion To evaluate the impact of bariatric surgery on the pharmacokinetic (PK) parameters of orally administered medications and supplements.Systematic searches of bibliographic databases were conducted to identify studies. Pooled effect estimates from different surgical procedures were calculated using a random‐effects model.Quantitative data were synthesized from 58 studies including a total of 1985 participants. Whilst 40 medications and 6 supplements were evaluated across these studies, heterogeneity and missing information reduced the scope of the meta‐analysis to the following medications and supplements: atorvastatin, paracetamol, omeprazole, midazolam, vitamin D, calcium, zinc, and iron supplements. There were no significant differences in PK parameters post‐surgery for the drugs atorvastatin and omeprazole, and supplements calcium, ferritin, and zinc supplements. Paracetamol showed reduced clearance (mean difference [MD] = −15.56 L/hr, p = 0.0002, I2 = 67%), increased maximal concentration (MD = 6.90 μg/ml, p = 0.006, I2 = 92%) and increased terminal elimination half‐life (MD = 0.49 hr, p < 0.0001, I2 = 3%) post‐surgery. The remaining 36 medications and 2 supplements were included in a systematic review. Overall, 18 of the 53 drugs and supplements showed post‐operative changes in PK parameters.This study demonstrates heterogeneity in practice and could not reach conclusive findings for most PK parameters. Prospective studies are needed to inform best practice and enhance patient healthcare and safety following bariatric surgery. [ABSTRACT FROM AUTHOR]

The article comments on a study which examined physical activity and heart rate variability in older people. Topics covered include factors that reduce resting heart rate (HR), variables considered in the assessment of autonomic nervous system function, and facts about HR variability (HRV), a surrogate index of cardiac autonomic nerve function. Also cited are the activities associated with specific and favorable HRV indices.

The Look AHEAD trial did not show that a lifestyle modification programme aimed at weight loss could reduce the incidence of cardiovascular disease events. We attempt to address why this trial was 'negative', and emphasize that further randomized lifestyle modification trials focusing on the effects of physical activity and exercise are needed. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Cardiac dysfunction during exercise in uncomplicated type 2 diabetes," by Judith G. Regensteiner, T.A. Bauer and Jane E. Reusch.

Latent class growth analysis is increasingly proposed as a solution to summarize the observed longitudinal treatment into a few distinct groups. When latent class growth analysis is combined with standard approaches like Cox proportional hazards models, confounding bias is not properly addressed because of time-varying covariates that have a double role of confounders and mediators. We propose to use latent class growth analysis to classify individuals into a few latent classes based on their medication adherence pattern, then choose a working marginal structural model that relates the outcome to these groups. The parameter of interest is defined as a projection of the true marginal structural model onto the chosen working model. Simulation studies are used to illustrate our approach and compare it with unadjusted, baseline covariates adjusted, time-varying covariates adjusted, and inverse probability of trajectory groups weighted adjusted models. Our proposed approach yielded estimators with little or no bias and appropriate coverage of confidence intervals in these simulations. We applied our latent class growth analysis and marginal structural model approach to a database comprising information on 52,790 individuals from the province of Quebec, Canada, aged more than 65 and who were statin initiators to estimate the effect of statin-usage trajectories on a first cardiovascular event. [ABSTRACT FROM AUTHOR]

In this article, the author discusses the concerns of obesity and obesity-related health risks. Topics discussed include independent association of obesity with cardiovascular disease, effect of body mass index (BMI) on survival rate of people, referring obesity as risk factor for heart failure and coronary artery disease, and use of waist-to-hip ratio (WHR) to measure central obesity.

Cardiorespiratory fitness (CRF) is positively associated with insulin sensitivity, whereas excessive levels of visceral adipose tissue (AT) and liver fat (LF) are both associated with insulin resistance and impaired plasma glucose-insulin homeostasis. To what extent levels of visceral AT and LF content contribute to the relationship between CRF and indices of plasma glucose-insulin homeostasis is uncertain. Our objective was to explore the interactions among CRF, visceral AT, and LF with glucose tolerance/insulin levels in asymptomatic and apparently healthy individuals. CRF was measured in 135 women and 177 men with a maximal treadmill graded exercise test. Indices of plasma glucose-insulin homeostasis were derived from a 3-h oral glucose tolerance test (OGTT) performed in the morning after a 12-h fast. Visceral AT levels and LF content were measured using magnetic resonance imaging and spectroscopy. For any given CRF level, women presented significantly lower visceral AT and LF than men as well as lower homeostasis model assessment of insulin resistance (HOMA-IR) and plasma glucose-insulin levels during the OGTT compared with men. In both sexes, there were significant negative correlations between CRF and HOMA-IR as well as glucose and insulin levels measured during the OGTT. Both glucose and insulin levels during the OGTT correlated positively with visceral AT and LF. In women and men, being in the top CRF tertile was associated with low levels of visceral AT and LF. Multivariable linear regression analyses suggested that visceral AT and LF were plausible mediators of the association between CRF and indices of plasma glucose-insulin homeostasis. [ABSTRACT FROM AUTHOR]

Background/purpose: Bariatric embolization of the left gastric artery (LGA) is being investigated as a technique to induce substantial weight loss in obese patients. Radial access is associated with less vascular complications than femoral access, especially in patients with severe obesity. We sought to assess the feasibility, safety and technical challenges of LGA angiography through radial access.Methods/materials: Patients with suspected coronary artery disease (CAD) and obesity (BMI > 30 kg/m2) referred for diagnostic catheterization and/or percutaneous coronary intervention (PCI) were eligible. After completion of diagnostic and/or PCI, selective cannulation of celiac artery was performed and images of the LGA were taken from multiple views. Detailed procedural parameters such as procedure time, contrast volume and radiation data as well as anatomical variations were assessed.Results: Between February and December 2018, we successfully achieved 50 selective angiographies of celiac artery from 54 enrolled patients (92.6%) and LGA was optimally visualized in 47/50 (97%) of cases. Right radial access was used in 50 cases. Mean age was 63.9 ± 8.0 years and 74% were men. Median BMI was 34.4 kg/m2 [32.2-39.4]. The median procedural time was 7 [5-10] minutes, contrast volume was 41 ml [33-63], fluoroscopy time was 160 [103-248] seconds and radiation exposure was 3125 [1906-4735] Gy.cm2. No complications were noted. The mean difficulty of the procedure on a visual analogue scale was 4/10.Conclusions: LGA angiography via transradial approach was feasible in the large majority of CAD patients with obesity. No safety issues were encountered. [ABSTRACT FROM AUTHOR]

Symptomatic thrombus formation due to a permanent pacemaker (PM) lead is a rare complication. It could be associated with serious outcome and should be suspected in patients who present with unexplained right heart failure, dyspnea, or syncope following dual‐chamber PM implantation. A timely decision to perform an echocardiographic examination, followed by medical, thrombolytic, or surgical treatment can be necessary. We describe the case of an 84‐year‐old man who presented with syncope and hypotension a few days after PM implantation. A transesophageal echocardiography revealed a mobile mass in the right atrium attached to the pacemaker lead. Intravenous heparin allowed a complete resolution of the thrombus. [ABSTRACT FROM AUTHOR]

Similarly, Barraclough et al. showed that canagliflozin consistently decreased the risk of major CV and kidney outcomes in patients with T2D, regardless of PAD status at baseline. The MACE benefit with canagliflozin in individuals with T2D, CKD and PAD translates into an ARR of -26.0 events/1000 patients over 2.5 years versus placebo. [Extracted from the article]

Cholesterol efflux capacities (CECs) are negatively associated with cardiovascular disease risk, irrespective of plasma high-density lipoprotein (HDL) cholesterol levels. Whether interventions targeting lifestyle improve HDL-CECs is unknown. Our objective was to determine whether improving dietary quality and increasing physical activity levels improves HDL-CECs in men with abdominal obesity and dyslipidemia. Our study sample included men (48 ± 8.5 yr) with an elevated waist circumference (≥90 cm) associated with dyslipidemia (triglycerides ≥1.69 and/or HDL cholesterol <1.03 mmol/l); 113 men completed a 1-yr intervention, consisting of a healthy eating and physical activity/exercise program, and 32 were included in a control group. An oral lipid tolerance test (OLTT) was performed in a subsample of 28 men who completed the intervention, and blood was collected every 2 h for 8 h. HDL-CECs were measured using [3H]cholesterol-labeled J774 macrophages and HepG2 hepatocytes. The lifestyle modification program led to an overall improvement in the cardiometabolic risk profile, increases in J774-HDL-CEC by 14.1% (+0.88 ± 1.09%, P < 0.0001), HepG2-HDL-CEC by 3.4% (+0.17 ± 0.75%, P = 0.01), and HDL cholesterol and apolipoprotein A-1 levels (13.5%, P < 0.0001 and 14.9%, P < 0.0001, respectively). J774-HDL-CECs and HepG2-HDL-CECs did not change in the control group. The best predictor for changes in HDL-CEC was apolipoprotein A-1 level. The lifestyle modification program also improved HDL-CEC response in postprandial lipemia during an OLTT. HDL-CEC did not change during the OLTT. Our results suggest that increasing physical activity levels and improving diet quality can have a positive impact on both HDL quantity and quality in men with abdominal obesity and dyslipidemia. [ABSTRACT FROM AUTHOR]

Purpose: Obesity is associated with left ventricular diastolic dysfunction and altered heart rate variability, as well as pulmonary dysfunction. The relationship between asthma and cardiac dysfunction in severely obese subjects is unknown, although it has been hypothesized that cardiac dysfunction may contribute to increase airway hyper-responsiveness (AHR). This study aimed to determine if AHR is associated with left ventricular diastolic dysfunction and heart rate variability in severely obese subjects.Methods: Sixty-one subjects with severe obesity (BMI ≥35 kg/m2 with comorbidities) completed this study. All subjects completed respiratory questionnaires, spirometry, lung volume measurements, methacholine inhalation test, 24hour Holter monitoring and a complete echocardiography evaluation. Blood samples were obtained for measurement of metabolic markers. Subjects with AHR, defined by a provocative concentration of methacholine inducing a 20% fall in FEV1 (PC20) < 8 mg/ml, were compared with those with no AHR (PC20 ≥8 mg/ml).Results: According to these criteria, 32 subjects had AHR and 29 had no AHR(mean PC201.70 mg/ml and 15.3 mg/ml respectively, p < 0.001). The groups were similar for anthropometric data and comorbidities. Fasting glucose, Hb1Ac, total cholesterol, LDL, triglycerides, Apo-B, C-reactive protein (CRP) and pro-BNP levels were also comparable between groups (p > 0.05). CRP level correlated with PC20 (AHR, r=0.38, p=0.03). Indices of heart rate variability and overall cardiac function were similar in subjects with or without AHR but grade 2 left ventricular diastolic dysfunction was more prevalent in subjects with AHR (p=0.037).Conclusions: Altered cardiac function, dysglycemia and dyslipidemia do not seem to be significantly associated with AHR in severely obese subjects in contrast to systemic inflammation. [ABSTRACT FROM AUTHOR]

Urbanization may influence physical activity (PA) levels, although little evidence is available for low- and middle- income countries where urbanization is occurring fastest. We evaluated associations between urbanization and total PA, as well as work-, leisure-, home-, and transport-specific PA, for 138,206 adults living in 698 communities across 22 countries within the Prospective Urban and Rural Epidemiology (PURE) study. The 1-week long-form International PA Questionnaire was administered at baseline (2003–2015). We used satellite-derived population density and impervious surface area estimates to quantify baseline urbanization levels for study communities, as well as change measures for 5- and 10-years prior to PA surveys. We used generalized linear mixed effects models to examine associations between urbanization measures and PA levels, controlling for individual, household and community factors. Higher community baseline levels of population density (− 12.4% per IQR, 95% CI − 16.0, − 8.7) and impervious surface area (− 29.2% per IQR, 95% CI − 37.5, − 19.7), as well as the rate of change in 5-year population density (− 17.2% per IQR, 95% CI − 25.7, − 7.7), were associated with lower total PA levels. Important differences in the associations between urbanization and PA were observed between PA domains, country-income levels, urban/rural status, and sex. These findings provide new information on the complex associations between urbanization and PA. [ABSTRACT FROM AUTHOR]

Purpose: β-Blockers (bisoprolol, carvedilol, and metoprolol) are the cornerstone of heart failure (HF) management. The incidence rate of β-blocker initiation and discontinuation and their associated factors among seniors with a first HF diagnosis were assessed. Methods: A population-based inception cohort study that included all individuals aged ≥65 years with a first HF diagnosis in Quebec was conducted. β-Blockers initiation among 91,131 patients who were not using β-blockers at the time of HF diagnosis and discontinuation among those who initiated a β-blocker after HF diagnosis were assessed. Stepwise Cox regression analyses were used to calculate hazard ratios (HR) and to identify factors associated with β-blocker initiation and discontinuation. Results: After HF diagnosis, 32,989 (36.2%) individuals initiated a β-blocker. Of these, 15,408 (46.7%) discontinued their β-blocker during the follow-up. Individuals more likely to initiate a β-blocker were those diagnosed in a recent calendar year (2009: HR, 2.11; 95% confidence interval [CI], 2.00-2.23) and diagnosed by a cardiologist (HR, 1.38; 95% CI, 1.34-1.42). Individuals less likely to initiate were those aged ≥90 years (HR, 0.65; 95% CI, 0.61-0.68) and those with chronic obstructive pulmonary disease (HR, 0.66; 95% CI, 0.64-0.68). Individuals more likely to discontinue were those with more than nine medical consultations (HR, 1.14; 95% CI, 1.10-1.18) and those with dementia (HR, 1.13; 95% CI, 1.01-1.27). Individuals less likely to discontinue were those diagnosed in a recent calendar year (2009: HR 0.74; 95% CI, 0.65-0.82) and those exposed to another β-blocker before HF diagnosis (HR, 0.88; 95% CI, 0.85-0.91). Conclusion: Quebec seniors seem to be underexposed to β-blocker following HF diagnosis. Among those who initiate β-blocker use, discontinuation is high. Better understanding of the underlying causes is needed to help target interventions to improve the management of HF. [ABSTRACT FROM AUTHOR]

The article discusses a study on the relation between prompt revascularization (PR) in medical therapy (MT) and mortality or cardiovascular (CV) events in patients with type 2 diabetes and coronary artery disease (CAD). The results of the study indicate a 30% relative reduction in mortality from 14% to 9.8%. Further, a difference was also found in the trials indicating a difference in the effects of PR and MT in major CV events.

The author reflects on the translation of cardiologists in abdominal obesity. He argues that studies have distinguished the major risk factors for cardiovascular disease (CVD) where some are non-modifiable and that many of these show lifestyle habits which includes a hurtful diet and lack of exercise that leads to obesity. He states that obesity has got through the epidemic ratios in the U.S. and is increasing in the growing world.

Presents a response to the commentary by Gillian Whalley et al., published in the July 2001 issue of `Diabetes Care,' stressing the importance of using the Valva maneuver to unmask left ventricular diastolic dysfunction in type 2 diabetic patients.

The article discusses the connection between exercise, physical Training and type 2 diabetes. The incidence and prevalence of diabetes mellitus are increasing dramatically throughout the developed world, and represent a major health problem in the U.S.. Exercise has long been recognized as an adjunct in the treatment of subjects with type 2 diabetes. Exercise and physical training have been shown to confer several beneficial effects in the non-diabetic population.

Purpose: The prevalence of numerous chronic metabolic diseases is increasing worldwide with considerable personal and societal consequences. The aim of our study was to test the hypothesis that assessment of waist circumference (WC) and of cardiorespiratory fitness (CRF) could be relevant clinical targets of a simple preventive approach designed to improve cardiometabolic risk (CMR) profile at the workplace. Methods: A total of 787 employees participated in a pilot project of the "Grand Défi Entreprise." This challenge involved a 3-month in-house competition to favor peer support in the adoption of healthier lifestyle habits. For that purpose, the participating companies offered a comprehensive cardiometabolic/cardiorespiratory health assessment performed at the workplace with a mobile risk assessment unit before and after the contest (nutrition/physical activity (PA) questionnaires, resting blood pressure (BP), anthropometric measurements, lipid profile, and submaximal treadmill test). Results: At baseline, more than 43% of workers were considered sedentary or moderately inactive (<3.5 h⋅wk-1 of physical activity). Furthermore, the proportion of subjects in the high-risk category of nutritional quality index (NQI) was high (49%). After 3 mo, NQI and PA level improved. Reductions in WC (-4.2 ±4.0 cm, P < 0.0001), in heart rate at a standardized submaximal workload (-4 ± 10 bpm, P < 0.0001) as well as in resting systolic (-6 ± 11 mm Hg) and diastolic (-4 ± 7 mm Hg) blood pressure were also observed. Improvements in WC and CRF were associated with improvements in the CMR profile. Conclusion: Results of this study show the added value of measuring/targeting WC and CRF as a relevant approach to reduce CMR at the workplace. Results also suggest that putting in place a permissive "in-house ecosystem" within the company is relevant to promote the adoption of healthier lifestyle habits. [ABSTRACT FROM AUTHOR]

While mounting evidence suggests that sleep plays an important role in the etiology of obesity, the underlying pathogenic pathways are complex and unresolved. Experimental sleep deprivation studies demonstrate sympathovagal imbalance, indicative of diminished parasympathetic activity and/or heightened sympathetic activity, is consequent to poor sleep. Further, obese children exhibit sympathovagal imbalance, particularly during the night, compared to non-obese children. The question remains whether sympathovagal imbalance is one potential pathophysiological pathway underlying the association between sleep and obesity. The aim of the present study was to examine whether sympathovagal imbalance contributed to the association between sleep and obesity in children. Participants included 564 children aged 10 to 12 years (M = 11.67, SD = 0.95; 43.5 % girls) from the QUALITY Cohort, a longitudinal study of children at-risk for the development of obesity. While children were at-risk due to confirmed parental obesity status, 57.7 % of children were of normal body mass index (5-85th percentile). Sleep duration, sleep timing, and sleep disturbances were based on child- and parent-report. Anthropometrics were measured for central adiposity (waist circumference) and body composition (body mass index, fat mass index). Sympathovagal imbalance was derived from heart rate variability spectral analyses. Estimated path coefficients revealed that sympathovagal imbalance partially contributed to the association between poor sleep (later bedtimes, sleep-disordered breathing) and obesity. These findings highlight the importance of better understanding sympathovagal imbalance and its role in the etiology and maintenance of obesity. Future research should consider investigating nocturnal sympathovagal balance in youth. [ABSTRACT FROM AUTHOR]

Heart rate variability (HRV) is a non-invasive quantitative marker of cardiac autonomic function derived from continuous electrocardiogram (ECG) recordings. Normative HRV values and development factors have not been established in pediatric populations. The objective was to derive referent time- and frequency-domain HRV values for a population-based sample of children. Children aged 9-11 years ( N = 1,036) participated in the Québec Longitudinal Study of Child Development cohort cardiovascular health screening. Registered nurses measured anthropometrics (height, weight) and children wore an ambulatory Holter monitor to continuously record an ECG signal. HRV variables included time (SDNN, pNN50, RMSSD, SDANN) and frequency (HF, LF, LF/HF ratio) domain variables. Normative HRV values, stratified by age, sex, and heart rate, are presented. Greater heart rate ( β = −0.60, R = 0.39), pubertal maturation ( β = −0.11, R = 0.01), later ECG recording times ( β = −0.19, R = 0.07), and higher diastolic blood pressure ( β = −0.11, R = 0.01) were significantly associated with reduced HRV in 10-year-old children. The normative HRV values permit clinicians to monitor, describe, and establish pediatric nosologies in primary care and research settings, which may improve treatment of diseases associated with HRV in children. By better understanding existing values, the practical applicability of HRV among clinicians will be enhanced. Lastly, developmental (e.g., puberty) and procedural (e.g., recording time) factors were identified that will improve recording procedures and interpretation of results. [ABSTRACT FROM AUTHOR]

Background: Recent evidence suggests that exposure to persistent organic pollutants (POPs) increases the risk of hypertension in environmentally exposed populations. High POP levels have been detected in Arctic populations and the exposure is related to high consumption of fish and marine mammals, which represent the traditional diet of these populations. Objective: We examined the associations between polychlorinated biphenyls (PCBs), organochlorine (OC) pesticides and hypertension among Inuit from Nunavik (Quebec, Canada). Methods: A complete set of data was obtained for 315 Inuit≥18years who participated in the “Santé Québec” health survey that was conducted in the 14 villages of Nunavik in 1992. Fourteen polychlorinated biphenyls (PCBs) and 8 OC pesticides or their metabolites were measured in plasma samples using gas chromatography with electron capture detection. Blood pressure (BP) was measured using a standardized protocol and information regarding anti-hypertensive medication was obtained through questionnaires. The associations between log-transformed POPs and hypertension (systolic BP≥140mmHg, diastolic BP≥90mmHg or anti-hypertensive medication) were analyzed using multiple logistic regressions. Results: Total PCBs as well as the sum of non-dioxin-like PCBs were significantly associated with higher risk of hypertension. Furthermore, the risk of hypertension increased with higher plasma concentrations of congeners 101, 105, 138 and 187. Models adjusted for BP risk factors became significant after including n−3 polyunsaturated fatty acids (PUFAs) and further adjustment for lead and mercury did not change the results. Regarding OC pesticides, p,p′-dichlorodiphenyldichloroethylene (p,p′-DDE) was associated with increased risk of hypertension while inverse associations were observed with p,p′-dichlorodiphenyltrichloroethane (p,p′-DDT), β-hexachlorocyclohexane (HCH) and oxychlordane. Conclusions: Some PCB congeners were associated with higher risk of hypertension in this highly exposed population. Most associations became significant after including n−3 PUFAs in the models. However, the analyses of OC pesticides revealed divergent results, which need to be confirmed in further cohort and experimental studies. [ABSTRACT FROM AUTHOR]

Background: Our purpose was to develop and test a predictive model of the acute glucose response to exercise in individuals with type 2 diabetes. Design and methods: Data from three previous exercise studies (56 subjects, 488 exercise sessions) were combined and used as a development dataset. A mixed-effects Least Absolute Shrinkage Selection Operator (LASSO) was used to select predictors among 12 potential predictors. Tests of the relative importance of each predictor were conducted using the Lindemann Merenda and Gold (LMG) algorithm. Model structure was tested using likelihood ratio tests. Model accuracy in the development dataset was assessed by leave-one-out crossvalidation. Prospectively captured data (47 individuals, 436 sessions) was used as a test dataset. Model accuracy was calculated as the percentage of predictions within measurement error. Overall model utility was assessed as the number of subjects with ⩽1 model error after the third exercise session. Model accuracy across individuals was assessed graphically. In a post-hoc analysis, a mixed-effects logistic regression tested the association of individuals' attributes with model error. Results: Minutes since eating, a non-linear transformation of minutes since eating, post-prandial state, hemoglobin A1c, sulfonylurea status, age, and exercise session number were identified as novel predictors. Minutes since eating, its transformations, and hemoglobin A1c combined to account for 19.6% of the variance in glucose response. Sulfonylurea status, age, and exercise session each accounted for <1.0% of the variance. In the development dataset, a model with random slopes for pre-exercise glucose improved fit over a model with random intercepts only (likelihood ratio 34.5, p < 0.001). Cross-validated model accuracy was 83.3%. In the test dataset, overall accuracy was 80.2%. The model was more accurate in pre-prandial than postprandial exercise (83.6% vs. 74.5% accuracy respectively). 31/47 subjects had ⩽1 model error after the third exercise session. Model error varied across individuals and was weakly associated with within-subject variability in pre-exercise glucose (Odds ratio 1.49, 95% Confidence interval 1.23-1.75). Conclusions: The preliminary development and test of a predictive model of acute glucose response to exercise is presented. Further work to improve this model is discussed. [ABSTRACT FROM AUTHOR]

Abstract: Background: Epidemiological evidence suggests a negative impact of methylmercury (MeHg) on cardiovascular risk factors such as blood pressure (BP) and heart rate (HR). This issue is of concern in Arctic populations such as in the Inuit of Nunavik since this contaminant is accumulated in fish and marine mammals, which still represent the subsistence diet of this population. Objective: We examined the associations between MeHg and BP and resting HR among Inuit adults. Methods: The “Santé Quebec” health survey was conducted in 1992 in the 14 villages of Nunavik and a complete set of data was obtained for 313 Inuit adults≥18 years. Blood samples were collected in order to determine total mercury, lead, total polychlorinated biphenyls (PCBs), n−3 polyunsaturated fatty acids (PUFAs), fasting glucose and lipid profile while socio-demographic variables were obtained through questionnaires. Anthropometric measurements as well as BP and resting HR were obtained using standardised protocols. Pulse pressure (PP: systolic BP minus diastolic BP) was also calculated. Multiple linear regression was used in order to determine the change in the dependent variables associated with the quartiles of MeHg concentration, taking the quartile 1 as reference. Results: The mean age of the participants was 38±14 years and the sample was composed of 132 men (42.2%) and 181 women (57.8%). MeHg geometric mean was 15.4μg/L (95%CI: 13.9–17.0) and levels ranged from 0.8 to 112.0μg/L. Resting HR increased linearly across quartiles of blood MeHg concentration after adjusting for confounders (p for trend=0.02). An increase of 6.9 beats per minute (bpm) between the 4th and 1st quartile was observed after adjusting for confounders. No significant association was observed between blood MeHg and systolic BP, diastolic BP or PP. Conclusions: MeHg was associated with increasing resting HR after considering traditional risk factors as well as other contaminants (lead and total PCBs) and n−3 PUFAs. In contrast, no significant association with blood pressure was observed in this study. [Copyright &y& Elsevier]

Abstract: Background: Studies conducted in the Faeroe Islands and Japan suggest a negative impact of mercury on heart rate variability (HRV) among children while the results regarding blood pressure (BP) are less consistent. Objective: To assess the impact of mercury on HRV and BP among Nunavik Inuit children. Methods: A cohort of 226 children was followed from birth to 11 years old. Mercury concentration in cord blood and in blood and hair at 11 years old were used as markers of prenatal and childhood exposure, respectively. HRV was measured using ambulatory 2h-Holter monitoring while BP was measured through a standardized protocol. Simple regression was used to assess the relationship of mercury to BP and HRV parameters. Multiple linear regressions were performed adjusting for covariates such as age, sex, birth weight, body mass index (BMI), height, total n-3 fatty acids, polychlorinated biphenyls (PCB 153), lead, selenium and maternal smoking during pregnancy. Results: Median cord blood mercury and blood mercury levels at 11 years old were 81.5nmoL/L (IQR: 45.0–140.0) and 14.5nmol/L (IQR: 7.5–28.0), respectively. After adjusting for the covariates, child blood mercury was associated with low frequency (LF) (β =−0.21, p =0.05), the standard deviation of R–R intervals (SDNN) (β =−0.26, p =0.02), the standard deviation of R–R intervals measured over 5min periods (SDANN) (β =−0.31, p =0.01) and the coefficient of variation of R–R intervals (CVRR) (β =−0.06, p =0.02). No significant association was observed with BP. Conclusion: Mercury exposure during childhood seems to affect HRV among Nunavik Inuit children at school age. [Copyright &y& Elsevier]

Reduced heart rate variability (HRV) is a predictor of poor outcome in several pathologies and in general population. Whether HRV is altered during normal daily activities or influenced by anticholinergic and β-adrenergic medications in chronic obstructive pulmonary disease (COPD) remains unknown. Forty-one clinically stable COPD patients and 19 healthy controls matched for age, sex and smoking history underwent a 24-hour ambulatory ECG recording during normal daily activities. HRV was assessed by standardized temporal and spectral analysis. COPD patients showed a reduced HRV (LF/HF ratio) compared with healthy controls (median [interquartile range]) during daytime (2.6 [1.5-3.8] vs. 3.5 [2.9-5.6]), nighttime (1.8 [1.1-4.3] vs. 4.2 [2.7-6.9]) as well as during the entire 24-hour (1.9 [1.5-3.4] vs. 3.9 [3.2-5.6]) recordings (all P < 0.005). There was no significant difference between the two groups in the time domain and in the low frequency or high frequency domain for the 24-hour period analysis. In COPD patients, the 24-hour LF/HF ratio positively correlated with forced expiratory volume in 1 second (FEV1) (r = 0.342, P = 0.028) and negatively correlated with age (r = −0.317, P = 0.044). In multiple regression analysis, LF/HF ratio was associated with FEV1 (P = 0.05) but not with age (P = 0.08). There was no difference of HRV between patients using or not anticholinergic or β-agonist medications. These results demonstrate that COPD patients have a reduced sympatho-vagal balance compared with healthy subjects. HRV correlates with disease severity and does not seem to be influenced by anticholinergic or adrenergic medications. [ABSTRACT FROM AUTHOR]