A multi-part panel discussion centered around management of lipid disorders in 2021 led by Practical Cardiology Advisory Board members.

Inside Cardiology: Lipid Management in 2021

This article was originally published on 

Data from an analysis of the multinational CLARIFY registry is helping to paint a clearer picture of the relationship between coronary syndromes and diabetes. 

The study found patients with chronic coronary syndromes were 3 times more likely to have diabetes and also revealed these patients were at a much greater risk of future cardiovascular events, including stroke, myocardial infarction, and cardiovascular death.

"Obesity and lack of exercise are common risk factors for both diabetes and heart disease and our results highlight the urgent need to improve nutrition and raise activity levels globally," said study lead investigator Emmanuelle Vidal-Petiot, MD, PhD, of Bichat-Claude Bernard Hospital, Paris, France,

. "Countries worst affected by diabetes are also at the epicentre of the obesity epidemic, which can be in part attributed to urbanization and associated changes in physical activity and food intake."

Published on World Health Day, the study was conducted by Vidal-Petiot and a team of colleagues with the intent of further exploring the prognostic impact of diabetes in patients presenting with chronic coronary syndromes. With this in mind, the study was designed as an analysis of data from within the CLARIFY registry.

A prospective, international registry, CLARIFY provided investigators with information related to more than 30,000 patients with stable coronary artery disease from 45 middle- and high-income countries followed for 5 years beginning in 2009-2010. For inclusion in the registry, patients needed to have had a documented myocardial infarction more than 3 prior, coronary angiography revealing a blockage of 50% or more, history of CABG or PCI more than 3 months prior, or proven symptomatic myocardial ischemia.

Of note, multiple investigators of the current study were on the executive committee or served as investigators in the original CLARIFY study. 

For the current analysis, investigators chose a composite outcome of cardiovascular death, myocardial infarction, and stroke as the primary outcome. Secondary outcomes for the analysis included each component of the primary outcome, total death, and hospitalization for heart failure.

After the exclusion of 9 patients from the CLARIFY registry due to lack of diabetes information, a cohort of 32,694 patients were identified for inclusion. Among these, 9502 (29%) had diabetes. Investigators noted the prevalence of diabetes ranged from 14% in Ireland to 67% in Saudi Arabia.

At the end of the 5-year follow-up period, 2807 patients had met the primary composite endpoint and 2544 patients had died, including 1619 who died from cardiovascular causes. When assessing secondary endpoints, investigators found stroke occurred in 686 patients, myocardial infarction occurred in 1106, 1647 patients were hospitalized for heart failure, and 2526 patients underwent coronary revascularization.

Upon analysis, all adverse clinical outcomes of interest occurred more frequently among patients diabetes. In adjusted analyses, patients with diabetes had a 28% greater risk for the primary composite outcome (aHR, 1.28; 95% CI, 1.18-1.39) and a greater risk for all secondary outcomes.

For secondary outcomes, patients with diabetes were at a 38% (HR, 1.38; 95% CI, 1.18-1.39) risk of all-cause death, a 39% (HR, 1.39; 95% CI, 1.25-1.54) greater risk of cardiovascular death, a 26% (HR, 1.26; 95% CI, 1.10-1.43) greater risk for myocardial infarction, a 29% (HR, 1.29; 95% CI, 1.09-1.52) greater risk of stroke, a 15% (HR, 1.15; 95% CI, 1.03-1.28) greater risk for hospitalization for heart failure, and a 14% (HR, 1.14; 95% CI, 1.04-1.25) greater risk of coronary revascularization.

"The importance of healthy eating and living cannot be overemphasized. Everyone can lower their chances of developing diabetes with weight control and exercise, and early detection is needed so that blood sugar can be controlled,” noted Vidal-Petiot. “Those with heart disease and diabetes also need an active lifestyle and a good diet to protect their health. Avoiding smoking is crucial, as is controlling blood pressure and cholesterol levels."

Prevalence of diabetes and impact on cardiovascular events and mortality in patients with chronic coronary syndromes, across multiple geographical regions and ethnicities

European Journal of Preventive Cardiology.

Articles

An analysis of the CLARIFY registry is providing clinicians with further insight into the impact of diabetes in patients with chronic coronary syndromes, particularly the increased risk of stroke, myocardial infarction, and cardiovascular death.

CLARIFY: Diabetes Poses Major Risk in Patients with Coronary Syndromes

: A 20-year-old female is brought to the emergency department by EMS for altered mental status. Her roommate found her lethargic in bed with the lights and music on and an empty bottle of vodka near her bedside. Medics state that the roommate told them she has a history of depression and just broke up with her girlfriend. She hadn’t seemed physically ill in the past few days but had been complaining of a headache.

: Vital signs are normal except for borderline tachycardia. On exam, she is lethargic with slurred speech to painful stimuli. Pupils are equal and react although a bit sluggishly. She has no obvious focal deficits but is unable to cooperate with the neurologic exam.

Computer Read: Rate 94, PR 254, QTc 395. Normal sinus rhythm with first-degree AV block. Nonspecific ST and T wave abnormality

Our latest case report from Dr. Brady Pregerson features a 20 y/o female brought to the emergency department by EMS for altered mental status. Check out the EKG and see if you can determine the diagnosis.

Case Report: Altered College Student

New research provides evidence suggesting survivors of preterm birth were at an increased risk of new-onset heart failure that persisted through adulthood.

An analysis of data from nearly 4.2 million patients in a Swedish birth registry dating back to 1973, results of the study indicate being born before 37 weeks gestational age was associated with a greater risk of heart failure at multiple stages of life—underlining the need for greater follow-up and monitoring of this patient population.

“To our knowledge, this is the largest population-based study of preterm birth in association with HF risks and the first to examine such risks into mid-adulthood or include cosibling analyses,” wrote investigators.

Spurred by an interest in furthering the understanding of preterm birth and cardiovascular risk later in life, a team led by Casey Crump, MD, PhD, of the Ichan School of Medicine at Mount Sinai, sought to address these apparent knowledge gaps using data from the Swedish Birth Register. Using a time frame of 1973-2018, the registry provided investigators with data related to 4,193,069 live singleton births, including 210,039 preterm births.

The median age of the study cohort was 22.5 years and the maximum age was 43 years. In total, investigators obtained data related to 85.0 million person-years of follow-up. Of those born preterm, 8324 were considered extremely preterm (22-27 weeks), 44,373 were moderately preterm (28-33 weeks), 157,342 were late preterm (34-36 weeks), and 740,391 were early term (37-38 weeks). In regard to the remaining patients, 2,896,444 were considered full term births and 346,195 were considered postterm births.

The primary outcome measure of the study was incident heart failure. For the purpose of analysis, investigates planned to use Cox regression to determine hazard ratios associated with each gestational age group while adjusting for perinatal and maternal factors. Investigators also planned additional cosibling analyses to assess for potential confounding by unmeasured familial factors.

Upon analysis, investigators identified 4158 patients as having heart failure. These patients had a median age at diagnosis of 15.4 (IQR, 28.0) years at diagnosis. Adjusted analyses indicated preterm birth, defined as earlier than 37 weeks, was associated with an increased risk of heart failure at ages younger than 1 year (aHR, 4.49; 95% CI, 3.86-5.22), 1-17 years (aHR, 3.42; 95% CI, 2.75-4.27), and 18-43 years (aHR, 1.42; 95% CI, 1.19-1.71) when compared to full term births.

At ages 18-43 years, the hazard ratios stratified by gestational age were 4.72 (95% CI, 2.11-10.52) for extremely preterm births, 1.93 (95% CI, 1.37-2.71) for moderately preterm births, 1.24 (95% CI, 1.00-1.54) for late preterm births, and 1.09 (95% CI, 0.97-1.24) for early term births. Investigators noted the corresponding incidence rates for patients at 18-43 years were 31.7, 13.8, 8.7, and 7.3, respectively, compared with 6.6 for full term births

Investigators included 3.5 million individuals in their cosibling analyses. Results of these analyses were similar to that of the primary analyses when assessing risk among patients younger than 18 years but substantially lower risks were no longer significant at ages 18-43 years.

, Mandy Brown Belfort, MD, MPH, of Brigham and Women’s Hospital, and Suzanne Brown Sacks, MD, MS, of Vanderbilt University School of Medicine, commended investigators on bringing attention to the importance of shifting focus to long-term health of survivors of preterm birth.

“The findings by Crump et al shed new light on heart failure as a long-term consequence of preterm birth and highlight opportunities for clinicians caring for preterm-born infants across the lifespan to understand their unique health risks and tailor their preventive and disease-specific care accordingly,” wrote the pair.

Association of Preterm Birth With Long-term Risk of Heart Failure Into Adulthood

An analysis of nearly 4.2 million patients from a birth registry indicates being born preterm was linked to a significantly higher risk of developing heart failure during childhood and a 42% greater risk of heart failure in adulthood.

Preterm Birth Associated with Increased Heart Failure Risk Throughout Adulthood

Patients with peripheral artery disease (PAD) who do not experience ischemic leg pain during their walking program could be failing to reach a threshold that provides any meaningful benefit, according to the results of a new trial from Northwestern Medicine.

Results of the study demonstrate participating in a low-intensity exercise program failed to achieve a meaningful difference compared to no exercise at all, while high-intensity walking that induced ischemic leg symptoms was associated with significant improvements in 6-minute walking distance and walking impairment at 12 months.

"We've shown you have to walk to elicit ischemic leg pain to reap the benefits," said lead investigator Mary McDermott, MD, professor of medicine at Northwestern University Feinberg School of Medicine, 

. "It will lessen over time, and most people eventually will be able to walk further without discomfort."

After a previous study found pain during exercise was a primary reason cited for inability to continue a walking program, McDermott and team designed the Low-Intensity Exercise Intervention in PAD (LITE) randomized clinical trial to assess whether a low-intensity walking exercise intervention that does not induce ischemic leg pain improved walking distance in patients with PAD compared to a high-intensity intervention inducing ischemic leg symptoms and a nonexercise control group.

Funded by a grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health, the LITE trial randomized 305 patients in a 120:120:65 ratio using a SAS computer program between September 25, 2015 and December 11, 2019. These patients were recruited from 4 US medical centers and followed for 12 months after randomization. Of note, the final follow-up occurred on October 7, 2020.

To be included in LITE, patients needed to have an ankle-brachial index (ABI) of 0.90 or less in either leg. Exclusion criteria for the trial included major amputation, a MiniMental State Examination score of less than 23, use of a walking aid other than a cane, having a walking limitation for a reason other than PAD, and having a significant visual or hearing impairment, among others.

Investigators received written informed consent from 441 patients with PAD and 305 underwent randomization. Of these, 116 patients were randomized to low-intensity walking, 124 were randomized to high-intensity walking, and 65 were randomized to the nonexercise control. The overall study population had a mean age of 69.3 (SD, 9.5) years, 47.9% were women, and 59.3% were Black. In total, 250 participants completed the 12-month follow-up.

Patients randomized to an exercise group were asked to walk for exercise 5 times per week for up to 50 minutes per session and wear an accelerometer to document exercise use intensity and time. For the purpose of analysis, the high-intensity group walked at a pace eliciting moderate to severe ischemic leg symptoms while the low-intensity group walked at a pace eliciting no ischemic leg symptoms.

The primary outcome for the trial was mean change in 6-minute walk distance at 12 months. Investigators pointed out a distance of 8-20 meters was used as a threshold for minimum clinically important difference at 12 months.

Upon analysis, investigators found 6-minute walk distance had changed from 332.1 meters at baseline to 327.5 meters in the low-intensity exercise group (within-group mean change, -6.4 meters; 95% CI, -21.5 to 8.8; 

=.34) and from 338.1 meters to 371.2 meters in the high-intensity exercise group (within-group mean change, 34.5 meters; 95% CI, 20.1 to 48.9; 

 <.001) at 12-month follow-up. Based on these results, investigators determined the mean change for the between-group comparison was -40.9 m (97.5% CI, -61.7 to -20.0; 

In the nonexercise control group, 6-minute walk distance changed from 328.1 meters at baseline to 317.5 meters at 12-month follow-up p (within-group mean change, -15.1 meters; 95% CI, -35.8 to 5.7; 

=.10), which investigators highlighted was not significantly different from the change observed in the low-intensity exercise group (between-group mean change, 8.7 meters; 97.5% CI, -17.0 to 34.4; 

A safety analysis revealed 2 serious adverse events were considered study-related. These events were a transient supraventricular arrhythmia developing after the baseline exercise stress test and needing to undergo coronary artery stent placement after chest discomfort developed while exercising in the low-intensity group.

McDermott and colleagues noted future plans to evaluate the biological expiation for the association between ischemia of the lower extremities and apparent benefit from walking exercise.

Effect of Low-Intensity vs High-Intensity Home-Based Walking Exercise on Walk Distance in Patients With Peripheral Artery Disease

Results of a 305-patient trial indicate ischemic leg pain could serve as a threshold for whether or not a patient with peripheral artery disease will see a meaningful improvement in walking score from their walking routine. 

LITE Trial: Low-Intensity Walking Provides Little to No Benefit for PAD Patients

6:50 - Barriers to Incorporating PROs in Practice

In this episode, Stephen Greene, MD, of the Duke Clinical Research Institute, breaks down a recent study he led comparing the sensitivity of NYHA class versus patient-reported outcomes for capturing changes in disease state among patients with heart failure with reduced ejection fraction.

Briefly, the study used data from the CHAMP-HF registry to identify a cohort of more than 2k HFrEF patients and found PRO, as measured by the Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OS), was more sensitive and better at tracking meaningful changes in health status over time when compared to use of NYHA class.

For more on use of KCCQ-OS vs. NYHA class, check out our coverage of Greene's study. 

Podcasts

Hear from Stephen Greene, MD, as he takes a deeper dive into a recent study he led comparing use of NYHA class vs. KCCQ-OS to capture changes in disease state among patients with heart failure with reduced ejection fraction. 

Implementation and Use of Patient-Reported Outcomes in Heart Failure with Stephen Greene, MD

Prior to COVID-19, many saw the advent of telehealth as an event that was years, if not decades, away for many specialties, including cardiology.

Now, it is hard to imagine where the field would be without the rapid adoption of telehealth services and a recent study from the Smidt Heart Instituteat Cedars-Seniai Medical Center suggests these new approaches could be helping to streamline practice.

"We were encouraged to learn that access to cardiovascular care was maintained for high-risk and underserved communities during the pandemic," said Joseph Ebinger, MD, director of Clinical Analytics in the Smidt Heart Institute and senior investigator of the study, 

. "This same study, however, identified some differences in care that we need to delve into further to better understand."

With adoption taking place in real-time, few studies have examined whether a transition to remote care has led to changes in patient access to care, ordering of diagnostic tests, or medication prescribing. To learn more about potential disparities in these areas, Ebinger and colleagues from Cedars-Sinai Medical Center designed performed a cross-sectional study using data from electronic health records of patients at Cedars-Sinai-affiliated medical centers before and during the pandemic.

For the purpose of analysis, the pre-pandemic period examined by investigators was defined as April 1, 2019-December 31, 2019 and the COVID-19-era period was defined as April 1, 2020-December 31, 2020. For the purpose of analysis, the primary exposure was defined as an in-person or a remote ambulatory visit at 1 of the 31 sites included in the study.

In total, investigators identified 176,781 ambulatory cardiology visits. Of these, 87,182 were in-person visits occurring during the pre-COVID-19 period and 74,498 were COVID-19-era in-person visits. The remaining consisted of 4720 COVID-19 era video visits and 10,381 COVID-19 era telephone visits.

Among all visits, 45% of patients were female, 71.9% were non-Hispanic White, and the mean age of patients was 68.1 (SD, 17.0) years. Upon analysis, investigators found significant differences in the baseline characteristics among patients undergoing the 4 visit types.

Patients using telehealth mediums during COVID-19 were more likely to be Asian, Black, or Hispanic individuals (24 934 pre-COVID in-person visits [28.6%] vs 19 742 COVID-era in-person visits [26.5%] vs 3633 COVID-era video visits [30.4%] vs 1435 COVID-era telephone visits [35.0%]; 

 < .001 for all comparisons). Additionally, these patients were also more likely to have private insurance and had a greater prevalence of cardiovascular comorbidities (

After adjustment for patients and visit characteristics, clinicians had lower odds of ordering any medication or tests, including echocardiograms and electrocardiograms, during COVID-19-era video or telephone visits.

"Our data reveal a reduced rate of testing and prescribing, likely due to a number of factors," added Ebinger. "We see these results as being not obviously negative or positive but a trend that is important to understand. For instance, lower rates of testing and prescribing may-in many instances-reflect reductions in the types of care that are not really needed to achieve good health outcomes while adding costs to the system."

In the aforementioned statement, Ebinger also noted plans to further examine the topic, including whether the change in number of tests could predispose to missed diagnoses.

Patient Use and Clinical Practice Patterns of Remote Cardiology Clinic Visits in the Era of COVID-19,

An analysis of data from Cedars-Sinai medical centers suggests the shift to telemedicine during the pandemic led to a reduction in a number of diagnostic tests and medications prescribed when compared to rates of both during the pre-pandemic era. 


Transition to Telemedicine Practices May Have Streamlined Care in Cardiology Clinics

A new study is calling for greater attention to treatment choices for managing 

 among patients with human immunodeficiency virus (HIV).

With people with HIV at an increased risk of hypertension as a result of antiretroviral therapy (ART), results from the study suggesting many of these patients were not receiving guideline-recommended medications for treatment is seen as a major red flag among study investigators.

“We suspected there could be differences in risk based on which medications providers select to treat hypertension among people with HIV due to potential interactions between blood pressure medications and some therapies used to treat the virus. Additionally, factors such as how the body handles salt, inflammation and the accelerated aging of blood vessels may affect the risk of cardiac events in people with HIV differently than people who do not have HIV, which could be influenced by which blood pressure medication is used,” said study investigator Jordana B. Cohen, MD, MSCE, assistant professor of medicine and epidemiology in the renal-electrolyte and hypertension division in the Perelman School of Medicine at the University of Pennsylvania, 

Thanks to advances in care and ART, patients with HIV have seen their life expectancies skyrocket in recent decades. However, a common result of ART is development of hypertension, which results in an increase in long-term risk of cardiovascular disease. Cohen and a team of colleagues designed their current analysis with the intent of using data from the Veterans Health Administration database to learn more about the interaction between use of certain blood pressure medications on risk of cardiovascular events in this population.

For the purpose of analysis, investigators identified veterans with HIV and incident hypertension using the database’s antihypertensives in obesity management cohort, which included more than 1 million veterans with incident hypertension from 2000-2018. Using propensity-score matching, investigators hoped to evaluate risk of incident and recurrent cardiovascular disease or death, incident cardiovascular disease, and incident heart failure stratified by antihypertensive class.

In total, investigators identified 8041 patients with HIV and incident hypertension for their analysis. Among these, 6516 did not have cardiovascular disease, peripheral arterial disease, or arrhythmia at baseline. The mean age of the study cohort was 53 (SD, 9 ) years, 97% were men, and 49% were Black.

At baseline, 74% of patients were receiving ART and 82% were initiated on antihypertensive monotherapy. The most common antihypertensive medications in the cohort were ACEs/ARBs (24%), diuretics (23%) beta-blockers (13%), and calcium channel blockers (11%). Over a median follow-up of 6.5 years, 25% of participants experienced a cardiovascular disease event and 27% died.

When compared to ACEs/ARBs, beta-blockers were associated with an increased risk of incident cardiovascular disease (HR, 1.90; 95% CI, 1.24-2.89). This increased risk was not seen among calcium channel blockers (HR, 1.02; 95% CI, 0.77-1.34) or diuretics (HR, 1.06; 95% CI, 0.86-1.31) when compared to ACEs/ARBs. Investigators noted similar risk was observed when using incident and recurrent cardiovascular disease or death as the primary outcome.

In subgroup analyses of veterans without chronic kidney disease, ACEs/ARBs were associated with a lower risk of incident heart failure when compared to the other drug classes included in the analyses.

“Patients with HIV need heightened attention to their elevated risk of heart disease. More dedicated research studying the unique needs for people with HIV and those taking ARTs is needed in order to optimize cardiovascular prevention,” Cohen said.

Antihypertensive Class and Cardiovascular Outcomes in Patients With HIV and Hypertension

An analysis of more than 8000 patients with HIV and hypertension suggests these patients may not be receiving the most efficacious antihypertensive agents and this could be placing these patients at increased risk of cardiovascular disease events or death. 

Study Calls for Change in Prescribing Practices of Antihypertensive Agents in Patients with HIV 

Lipid Management in 2021

Case Report: Extreme Risk Patient w/ Diabetes

Case Report: Very High-Risk Patient

Future Therapies in Lipidology

Telehealth in Cardiology

Videos

In this edition of Inside Cardiology, a trio of advisory board members discuss a series of case reports, upcoming and newly released therapies for lipid disorders, and use of telehealth for the management of patients. 

Patients with primary non-familial hyperlipidemia or homozygous familial hypercholesterolemia have a new option for reducing LDL-C thanks to the FDA approval of rosuvastatin and ezetimibe (Roszet), 

according to a statement from Althera Pharmaceuticals

Approved as an adjunct to diet for the treatment of elevated LDL-C in adult patients, the oral combination therapy was shown to lower LDL-C by up to 64% and is expected to be available in pharmacies in June 2021.

“The optimal LDL-C levels in guidelines across the world have been shifting lower and now many patients need to get their LDL-C below 70 mg/dL,” said Christie Ballantyne, MD, Chief of Cardiology and Cardiovascular Research at Baylor College of Medicine, in the aforementioned statement. “These levels can be quite difficult to achieve with just a statin on top of diet and exercise. Rosuvastatin and ezetimibe have been extensively studied in combination therapy and have been shown to significantly reduce LDL cholesterol beyond the statin alone.”

A combination therapy using rosuvastatin, a high-potency HMG-CoA reductase inhibito

, and ezetimibe, a selective cholesterol absorption inhibitor, the statement from Althera Pharmaceuticals noted research from multiple studies indicate rosuvastatin and ezetimibe have the potential to reduce LDL-C by as much as 72% with the 40 mg/10 mg dose and by 64% with the 10 mg/10 mg dose.

According to the release from Althera, rosuvastatin and ezetimibe will be available in dosages of 5 mg/10 mg, 10 mg/10 mg, 20 mg/10 mg, and 40 mg/10 mg. Additionally, the release note rosuvastatin and ezetimibe is contraindicated in patients with hypersensitivity to any component of rosuvastatin and ezetimibe and in patients with active liver failure or decompensated cirrhosis.

“With Roszet’s approval in the U.S., we reaffirm our commitment to improving cholesterol treatment options for physicians and patients,” said Sanjeev Agarwal, CEO of Althera Pharmaceuticals. “We are on a mission to positively impact patients’ health. By making this highly effective medicine available and affordable, we hope to improve the long-term health of patients, including those with prior cardiovascular disease.”

Althera Pharmaceuticals also noted the Roszet Savings Program aims to reduce co-pays for eligible patients with commercial insurance coverage to as little as $20 per month.

“Combination therapy has been widely used in hypertension to achieve lower blood pressure targets. This new therapy provides a high efficacy statin plus ezetimibe in a single once daily pill which is a powerful new option to help get patients to the desirable LDL goal without increasing pill burden or requiring addition of injectable therapies,” added Ballantyne.

Althera Pharmaceuticals announced the FDA approved rosuvastatin and ezetimibe (Roszet) as an adjunct to diet for lowering LDL-C in adults patients with primary non-familial hyperlipidemia or homozygous familial hypercholesterolemia.

Rosuvastatin/Ezetimibe Combination Therapy Approved for Lowering LDL-C

Stress has long been associated with a variety of medical conditions. Theories for this range from an increase in detrimental behaviors like eating, drinking, and smoking to systemic inflammation created by heightened sympathetic nervous system activity. Intense psychosocial stress has been associated with some severe forms of cardiac disease.

A form of heart failure known as Takotsubo cardiomyopathy, which is predominantly found in women, can occur after intense emotional stress such as the loss of a spouse and is known as broken heart syndrome. Dr. Dimitriy Panov, of the Institute of Cytology and Genetics, in Novosibirsk, Russia sought to determine if men experiencing extreme fatigue and stress, a condition called vital exhaustion, are at higher risk for heart attack than the general male population. Dr. Panov presented his findings at the ESC Acute CardioVascular Care 2021 Online Congress on March 14, 2021.

When asked what vital exhaustion is Dr. Panov states:

"Vital exhaustion refers to excessive fatigue, feelings of demoralization and increased irritability."

The purpose of this study was to see if heart attacks were occurring in men without prior cardiovascular disease who were suffering from vital exhaustion. Vital exhaustion was measured utilizing the Maastricht Vital Exhaustion Questionnaire and data were extracted from the World Health Organization via the MONICA project.

Vital exhaustion is thought to stem from exposure to intractable problems in the individual’s life including prolonged exposure to psychological stressors. Symptoms were classified as none, moderate, or high and patients were followed for 14 years with the primary outcome being experiencing a heart attack.

Dr. Panov and colleagues found that over two-thirds of the men studied had suffered from vial exhaustion. When compared to those without vital exhaustion, men with moderate or high levels had a nearly 3-fold greater risk of a heart attack within five years, a 2 ¼-fold greater risk within 10 years, and a 2-fold greater risk over 14 years. Interestingly the risk of heart attack in men with vital exhaustion was higher in widowed, divorced, and never married men than in married men. Dr. Panov believes that the reason for this finding is less social support.

"Living alone indicates less social support, which we know from our prior studies is an independent risk factor for myocardial infarction and stroke."

These findings could not have come at a better time. Over the last year, the global pandemic of COVID-19 has led to dramatic increases in social isolation, psycho-social and economic stress, and has resulted in unprecedented mortality leaving countless loved ones without a spouse, parent, or sibling. This combination of stressors represents a perfect storm capable of significantly increasing the incidence of vital exhaustion in the greater population. To make matters worse, evidence suggests that people experiencing acute coronary syndromes may be delaying or even foregoing travel to the hospital out of fear of coronavirus. We have to do better, on several levels, to combat these challenges head-on.

Looking at ways we can make a difference in this population, Dr. Panov suggests,

"Efforts to improve well-being and reduce stress at home and at work can help reduce vital exhaustion. Involvement in community groups is one way to increase social support and become less vulnerable to stress. Together with a healthy lifestyle, these measures should be beneficial for heart health."

Identifying men at risk for or experiencing vital exhaustion may prevent subsequent heart attacks if mitigating strategies aimed at reducing stress, eliminating isolation, and improving overall wellbeing are put into action. This may be accomplished through identification in the primary care setting of those at highest risk. This is a situation where mental health is closely linked to physical health and we as clinicians must look at the whole patient so as not to miss the forest for the tress. As specialists it is easy to focus on cardiovascular issues, that’s what we do, but we should be able to recognize the signs of vital exhaustion and realize that, even in seemingly healthy patients, the risk may be heightened for heart attacks.

Finally, credit should be given to Dr. Panov and colleagues for illuminating a hidden killer. In a time when mental health is in a fragile state, special attention should be paid to the effect extreme stress has on the hearts as well as the minds of men struggling to get by. Front line clinicians are the gatekeepers and with watchful eyes, we can protect their hearts and their lives.

Vital exhaustion and risk of myocardial infarction in male population aged 25- 64 years in Russia/Siberia. Epidemiological program WHO Monica-psychosocial

," was presented virtually as part of the ESC Acute CardioVascular Care 2021 Online Congress.

A study from the ESC Acute CardioVascular Care 2021 Online Congress is providing clinicians with further insight into the effects of psychosocial stress on the cardiovascular health of men. 