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The American College of Cardiology has released a special “almanac-style” issue of their flagship journal they hope will bring new attention to troubling trends related to the global burden of cardiovascular disease.

Published on December 12, the special issue of the 

journal of the American College of Cardiology

 shines a spotlight on 18 specific cardiovascular conditions and 15 risk factors across 21 global regions to provide clinicians and the general public with a more complete overview of burden cardiovascular disease is placing on health systems and societies across the globe, with the document serving as an update to their previous iteration, titled “The Global Burden of Diseases, Injuries, and Risk Factors Study 2019”.

“We need to keep shining a light on the current state of cardiovascular health across the globe. Cardiovascular health has a major impact on our quality of life and the health care system as a whole,” said Gregory A. Roth, MD, MPH, senior author of the paper and associate professor in the Division of Cardiology and director of the Program in Cardiovascular Health Metrics at the Institute for Health Metrics and Evaluation at the University of Washington, in 

. “Over 80% of cardiovascular disease is preventable. With this update, we are measuring some alarming global trends and reviewing the current interventions that can help countries make good, evidence-based choices for their health systems.”

A product of the Global Burden of Cardiovascular Diseases Collaboration, which is an alliance between 

, the Institute for Health Metrics and Evaluation, and the National Heart, Lung, and Blood Institute, the report clocks in at 54 pages in length and boasts reports related to cardiovascular disease burden for 21 distinct regions, with these regions defined by location and further stratified according to income. The report itself was created by using vital and sample registration data. Within the report is estimates for the leading 15 environmental, metabolic, and behavioral risks of cardiovascular disease. Additionally, the report breaks down cardiovascular disease mortality rates, disability-adjusted life years (DALYs), the years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) for each region included in report since 1990.

In the aforementioned statement, the ACC called attention to 6 specific trends within the report they deemed noteworthy. These 6 are listed below:

Ischemic heart disease is the leading cause of cardiovascular death, accounting for 9.44 million deaths in 2021 and 185 million DALYs.

High systolic blood pressure remains the leading modifiable risk factor for premature cardiovascular deaths, accounting for 10.8 million CV deaths and 11.3 million deaths overall in 2021. The all-cause DALYs due to high blood pressure were 2,770 per 100,000 people.

Dietary risks accounted for 6.58 million CV deaths and 8 million deaths overall in 2021. Dietary risks include food types that are under-consumed globally (fruits, vegetables, legumes, whole grains, nuts and seeds, milk, fiber, calcium, omega-3 fatty acids and poly unsaturated fatty acids) and over-consumed (red and processed meats, sugar-sweetened beverages, trans-fatty acids and sodium). All-cause DALYs due to dietary risks were 2,340 per 100,000 people.

Central Asia, Central Sub-Saharan Africa and Eastern Europe were the regions with the highest rates of CVD burden attributable to elevated systolic blood pressure. The regions with the highest rates of CVD burden attributable to dietary risk were Central Asia, Oceania and Eastern Europe.

Central Asia had the highest age-standardized total CVD mortality at 516.9 deaths per 100,000. In contrast, high-income Asia Pacific had the lowest age-standardized total CVD mortality at 76.6 deaths per 100,000 people.

Since 1990, Australasia had the largest percent reduction (64.2%) in age-standardized CVD per 100,000 out of all other regions. This percent decrease was highest in ischemic heart disease at 71.8%.

“It is truly exciting to see this multi-year Global Burden of Cardiovascular Diseases Collaboration culminate into a dedicated issue of the Journal to inform the global cardiovascular community,” said Valentin Fuster, MD, PhD, an author of the paper, director of Mount Sinai Heart, physician-in-chief of The Mount Sinai Hospital and editor-in-chief of 

. “This issue focuses both on the modifiable risk factors, as well as the global cardiovascular disease and death rates in 21 regions across the world.”

Global Burden of Cardiovascular Diseases and Risks Collaboration

Journal of the American College of Cardiology.

Articles

Released on December 12, the ACC's "Global Burden of Cardiovascular Diseases and Risks Collaboration" report provides an overview of trends in cardiovascular disease from 21 distinct regions defined by location and income level. 

American College of Cardiology Releases Global Report on Cardiovascular Disease Burden

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The American Heart Association (AHA) has released a scientific statement offering clinicians with updated age-specific guidance related to diagnosis and management of acute coronary syndromes (ACS) in older patients.

With the proportion of older adults in the US continuing to increase, the AHA’s latest scientific statement provides timely and relevant information centered around diagnosis and management of ACS in people aged 75 years or older.

“Older patients have more pronounced anatomical changes and more severe functional impairment, and they are more likely to have additional health conditions not related to heart disease,” said Abdulla A. Damluji, MD, PhD, chair of the scientific statement writing committee, director of the Inova Center of Outcomes Research, and an associate professor of medicine at Johns Hopkins School of Medicine in Baltimore, 

. “These include frailty, other chronic disorders (treated with multiple medications), physical dysfunction, cognitive decline and/or urinary incontinence – and these are not regularly studied in the context of ACS.”

Published on December 12, the statement was prepared by a volunteer writing committee composed of Damluji and 9 colleagues on behalf of several AHA councils, including the Cardiovascular Diseases in Older Populations Committee of the Council on Clinical Cardiology, the Council on Cardiovascular and Stroke Nursing, the Council on Cardiovascular Radiology and Intervention, and the Council on Lifestyle and Cardiometabolic Health. At 31 pages in length and citing 197 references, the authors outlined the specific aims of their statement within the abstract of the document. These specific aims were listed as reviewing age-related physiological changes that predispose to acute coronary syndrome and management complexity, describing the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes, and recommending age-appropriate and guideline-concordant revascularization and ACS management strategies.

With this in mind, the statement has 9 sections dedicated to topics ranging from cardiovascular aging to GDMT for ACS and transitions, rehabilitation, and follow-up. Within the 9 sections are one or more subsections, considerations for clinical practice, and key points as well as several tables and graphs depicting best practices, trial evidence, physiologic changes impacting pharmacokinetics and pharmacodynamics of medications in older adults.

“Geriatric syndromes and the complexities of their care may undermine the effectiveness of treatments for ACS, as well as the resiliency of older adults to survive and recover,” Damluji added. “A detailed review of all medications – including supplements and over-the-counter medicines – is essential, ideally in consultation with a pharmacist who has geriatric expertise.”

Within the aforementioned statement from the AHA, the organization calls specific attention to a group of clinical considerations in the document related to normal aging and age-related changes in the heart and blood vessels. Some of these considerations are highlighted below:

ACS is more likely to occur without chest pain in older adults, presenting with symptoms such as shortness of breath, fainting or sudden confusion.

Troponin levels may already be higher in older people, especially those with kidney disease and a stiffened heart muscle. Evaluating patterns of the rise and fall of troponin levels may be more appropriate when using it to diagnose heart attacks in older adults.

Age-related changes in metabolism, weight and muscle mass may necessitate different choices in anti-clotting medications to lower bleeding risk.

As kidney function declines, the risk of kidney injury increases, particularly when contrast agents are used in imaging tests and procedures guided by imaging.

Although many clinicians avoid cardiac rehabilitation for patients who are frail, they often benefit the most.

A portion of the statement is also dedicated to patient preferences and life expectancy. Within this section, the authors provide perspective on goalsetting in the care of older patients and those palliative care touching upon quality of life metrics and discussions around potential do-not-resuscitate orders.

Management of Acute Coronary Syndrome in the Older Adult Population

Published on December 12, the American Heart Association's scientific statement on diagnosis and management of acute coronary syndromes in older adults provides a review of several important topics including physiological changes, the influence of common geriatric syndromes, and age-appropriate and guideline-concordant recommendations for this patient population. 

AHA Releases Scientific Statement on Acute Coronary Syndromes in Older Patients

A new analysis from the PARADIGM-HF study suggests substantial overlap exists in regard to the objective measures and long-term prognosis of patients with NYHA Class I and II heart failure.

Using data from the PARADIGM-HF trial, investigators produced results they suggest underline the potential limitations of using NYHA classification to differentiate mild forms of heart failure.

“In a large contemporary [heart failure] trial with systematic data collection and blinded adjudicated end points, time-honored NYHA classification could discriminate subgroups of increased risk but was incomplete to characterize critical aspects related to [heart failure], particularly for patients with mild functional limitation,” wrote investigators. “Across different NYHA classes, we observed considerable overlap in objective measures of [heart failure].”

As knowledge and technology advances, the need to identify objective measures for optimal classification of heart failure patients has become a focal point of many research endeavors. Among the long-time staples which have seen their utility questioned recently are ejection fraction and, now, NYHA class.

In the current study, investigators designed their secondary analysis with the specific intent of assessing within-patient variation in NYHA classification over time, the association between NYHA class and an objective measure of heart failure severity NT-proBNP level, and their association with long-term prognosis in the PARADIGM-HF trial. To do so, investigators leveraged data from those in classified as NYHA class I, II, and III at randomization after the 6–10-week run-in period from within the parallel-design, double-blind PARADIGM-HF trial.

Investigators obtained data from 8326 patients with known NYHA classification at randomization from the trial. Of these 389 were classified as NYHA class I, 5919 were classified as NYHA class II, and 2018 were classified as NYHA class III. compared with NYHA class II and III, those classified as NYHA class I at randomization were younger, were more frequently men, and had fewer comorbidities.

Among the 389 patients classified as having NYHA class I heart failure at randomization, 58% changed functional class during the first year following randomization. Results of the investigators’ analysis indicated levels of NT-proBNP were a poor discriminator of NYHA classification, with an AUC of 0.51 (95% CI, 0.48-0.54) for NYHA class I versus class II. Additionally, for NT-proBNP level, investigators determined the estimated kernel density overlap was 93% between NYHA class I and class II, 79% between NYHA class I and class III, and 83% between NYHA class II and III.

Further analysis indicated those classified as having NYHA class III heart failure had a greater rate of cardiovascular events compared to those with NYHA class I (HR, 1.84 [95% CI, 1.44-2.37]) or class II heart failure (HR, 1.49 [95% CI, 1.35-1.64]). Those in NYHA class I had a lower rate of events than those in NYHA class II (HR, 1.24 [95% CI, 0.97-1.58]). Before concluding, investigators pointed out stratification into subgroups defined by NT-proBNP levels identified subgroups of patients with distinctive cardiovascular risk. Underlining this distinctive risk, investigators highlighted results suggesting patients with NYHA class I heart failure with high NT-proBNP levels had a numerically higher event rate than patients with low NT-proBNP from any NYHA class (vs I, HR, 3.43 [95% CI, 2.03-5.87]; vs II, HR, 2.12 [95% CI, 1.58-2.86]; vs III, HR, 1.37 [95% CI, 1.00-1.88]).

“NYHA classification dynamically changed over time and was an incomplete predictor of adverse outcomes, particularly in patients with mild [heart failure],” investigators concluded. “These findings challenge the use of NYHA class as the leading criteria to enroll patients in [heart failure] trials and to select therapeutic strategies in clinical guidelines.”

Associations Between New York Heart Association Classification, Objective Measures, and Long-term Prognosis in Mild Heart Failure

An analysis of data from the PARADIGM-HF trial provides insight into the utility of NYHA class for identifying risk among patients with mild forms of heart failure. 

NYHA Class Alone Fails to Accurately Discern Risk Among Heart Failure Patients

An analysis of health record data from patients in Denmark suggests statin use was associated with a lower risk of intracerebral hemorrhage in older patients.

A nested case-control registry study of more than 2000 patients with intracerebral hemorrhage and more than 45,000 matched controls, results of the study suggest long-term statin adherence was associated with a lower risk of both non-lobar intracerebral hemorrhage and lower intracerebral hemorrhage.

“While statins have been shown to reduce the risk of stroke from blood clots, there has been conflicting research on whether statin use increases or decreases the risk of a person having a first intracerebral hemorrhage,” said study investigator David Gaist, MD, PhD, of the University of Southern Denmark in Odense and a member of the American Academy of Neurology, 

 “For our study, we looked at the lobe and non-lobe areas of the brain to see if location was a factor for statin use and the risk of a first intracerebral hemorrhage. We found that those who used a statin had a lower risk of this type of bleeding stroke in both areas of the brain. The risk was even lower with long-term statin use.”

Statin therapy has established itself as a cornerstone in the management of cholesterol disorders since their introduction more than 3 decades. With mountains of data illustrating the anti-inflammatory effects of statin use as well as other benefits, the overall health benefits associated with statin use has become a focal point of a multitude of research efforts. Included among these research efforts is the current study, which was conducted by Gaist and a team of colleagues from Denmark and the US.

The study, which was sponsored by Novo Nordisk, was endeavored with the specific intent of examining associations between long-term statin exposure and intracerebral hemorrhage risk based on differing intracerebral hemorrhage locations. To do so, investigators designed their suited as a nested case-control leveraging data from linked Danish registries. From within the Southern Denmark Region, investigators identified all first-ever cases of intracerebral hemorrhage occurring from 2009-2018 among people aged 55 years or older.

After identification, these patients were classified as having a lobar or non-lobar intracerebral hemorrhage and were subsequently matched for age, sex, and calendar year to general population controls. Overall, 989 patients with lobar intracerebral hemorrhage were matched to 39,500 controls and 1175 patients with non-lobar intracerebral hemorrhage were matched to 46,755 controls. The cohort of patients with lobar intracerebral hemorrhage was 52.2% female and had a mean age of 76.3 years. The cohort of patients with non-lobar intracerebral hemorrhage was 46.5% female and had a mean age of 75.1 years. Investigators pointed out logistic regression adjusted for potential confounders was used to estimate adjusted odds ratios for risk of intracerebral hemorrhage.

Upon analysis, results indicated current statin use was associated with a. Lower risk of both lobar and non-lobar intracerebral hemorrhage. When assessing duration of use, results demonstrated longer duration of use was also associated with a reduction in risk of lobar intracerebral hemorrhage, with a reduced risk observed for those with at least 1 year but less than 5 years of use (aOR, 0.89 [95% CI, 0.73-1.09]) and those using statins for 5 years or more (aOR, 0.67 [95%CI, 0.51-0.87])(

for trend =.040). A similar trend was observed for non-lobar intracerebral hemorrhage, with a greater reduction in risk associated seen for those with at least 1 year but less than 5 years of use (aOR, 0.88 [95%CI, 0.73-1.06]) and those using statins for 5 years or more (aOR, 0.62 [95%CI, 0.48-0.80])(

“It’s reassuring news for people taking statins that these medications seem to reduce the risk of bleeding stroke as well as the risk of stroke from blood clots,” Gaist added. “However, our research was done in only the Danish population, which is primarily people of European ancestry. More research should be conducted in other populations.”

Association Between Statin Use and Intracerebral Hemorrhage Location: A Nested Case-Control Registry Study

Data from an analysis of patients in Denmark provides an overview of the effects of statin therapy on risk of intracerebral hemorrhage, with insights into how this benefit may vary based on the location of the intracerebral hemorrhage. 

Exposure to Statin Therapy Could Lower Risk of Brain Bleeds in Older Patients

In an effort to combat medical misinformation on the subject, the American Heart Association (AHA) has released a new scientific statement centered around the benefits and risks of using complementary and alternative medicines to manage symptoms of 

Using data published prior to November 2021, the AHA statement encourages providers to discuss use of complementary and alternative therapies and talk about potential medication interactions as well the benefits and potential side effects of use at every visit, noting use of complementary and alternative therapies is a practice among 30% of people with heart failure in the US.

“These products are not federally regulated, and they are available to consumers without having to demonstrate efficacy or safety to meet the same standards as prescription medications,” said Chair of the scientific statement writing committee Sheryl L. Chow, PharmD, an associate professor of pharmacy practice and administration at Western University of Health Sciences and associate clinical professor of medicine at the University of California in Irvine, 

. “People rarely tell their health care team about their use of supplements or other alternative therapies unless specifically asked, and they may not be aware of the possibility of interactions with prescription medicines or other effects on their health. The combination of unregulated, readily accessible therapies and the lack of patient disclosure creates significant potential for harm.“

Prepared on behalf of several AHA committees, including the Clinical Pharmacology Committee and Heart Failure and Transplantation Committee of the Council on Clinical Cardiology, the Council on Epidemiology and Prevention, and the Council on Cardiovascular and Stroke Nursing, the 27-page documents cites more than 200 references. Following the abstract and introduction, the writing committee provide perspective on global utilization and the influence of social determinants of health on use of these therapies.

A central portion of the document is dedicated to a pair of tables spanning 11 pages providing an overview of clinical efficacy studies of complementary and alternative medicines on heart failure and clinical studies of complementary and alternative medicines that interact with heart failure therapy or worsen heart failure, respectively. Later in the document, the writing committee provides a color-coded graphic listing the complementary and alternative medicines they consider to be potentially harmful, potentially beneficial, and those where safety is uncertain. The items supplements and activities included in these categories are detailed below.

“Overall, more quality research and well-powered randomized controlled trials are needed to better understand the risks and benefits of complementary and alternative medicine therapies for people with heart failure,” Chow added. “This scientific statement provides critical information to health care professionals who treat people with heart failure and may be used as a resource for consumers about the potential benefit and harm associated with complementary and alternative medicine products.”

Complementary and Alternative Medicines in the Management of Heart Failure: A Scientific Statement From the American Heart Association

Published on December 8, the AHA's scientific statement aims to combat medical misinformation by offering clinicians an overview of the contemporary knowledge base surrounding complementary and alternative medicine in patients with heart failure.

American Heart Association Releases Scientific Statement on Complementary and Alternative Medicine Use in Heart Failure

Nearly 3 years after approval from the US Food and Drug Administration for lowering LDL-C, data from the CLEAR Outcomes trial confirm bempedoic acid (NEXLETOL) use is associated with a statistically significant and clinically meaningful reduction in risk of major adverse cardiovascular events.

, the company expects to present comprehensive data at a medical conference in the first quarter of 2023 and suggests, with results, bempedoic acid becomes the first ATP citrate lyase inhibitor and first oral non-statin to meet the MACE-4 primary endpoint, which includes cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and unstable angina requiring hospitalization.

“With the announcement of these positive topline results, bempedoic acid becomes the first ATP-citrate lyase inhibitor to demonstrate significant and clinically meaningful outcomes results for patients in whom existing lipid lowering therapies fall short,” said Sheldon Koenig, President and CEO of Esperion. “We thank the thousands of patients and investigators worldwide for bringing this study to a successful close. We look forward to sharing this data with the medical community and submitting to appropriate regulatory authorities as quickly as possible in 2023. CLEAR Outcomes further strengthens the clinical evidence supporting the role of bempedoic acid for patients.”

Approved in 2020 based on the results of data from Esperion’s phase 3 CLEAR program, which included 4 phase 3 trials, many care providers expressed concern over the lack of outcomes data. A phase 3 trial, CLEAR Outcomes was designed as an event-driven, randomized, multicenter, double-blind, placebo-controlled trial with the aim of determining whether use of bempedoic acid was associated with reductions in risk of cardiovascular events in among a population of more than 14,000 patients with high risk for cardiovascular disease with documented statin intolerance and elevated LDL-cholesterol levels from more than 1200 sites in 32 countries.

In the pivotal trial used for the February 2020 approval of bempedoic acid, results suggested use was associated with an 18% reduction in LDL-C when used as an adjunct to maximally tolerated statin therapy and a 28% reduction when used in statin-averse patients. At the time this article was published, bempedoic acid was indicated by the FDA for use as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with HeFH or established ASCVD.

Check out more content, including expert perspective from CLEAR investigators, by clicking here!

Almost 3 years after approval, Esperion's announcement of positive results from the CLEAR Outcomes trial indicate bempedoic acid is the first oral non-statin therapy to meet the MACE-4 primary endpoint included in the outcomes trial of the ATP citrate lyase inhibitor. 

CLEAR Outcomes: Bempedoic Acid Reduces Cardiovascular Events

Bromocriptine, an agent used in the treatment of Parkinson disease, could prove useful in reducing the incidence and burden of hypertension and arterial stiffness in younger patients with type 1 diabetes, according to results of a new National Institutes of Health (NIH)-funded study.

An analysis of data from a 34-participant study examining blood pressure and aortic stiffness with the dopamine receptor agonist in adolescents with type 1 diabetes, results of the study demonstrate use was associated with a 5-mmHg reduction in systolic and 2-mmHg reduction in diastolic blood pressure after the 4-week intervention period, with results also pointed to reduced ascending aortic pulse wave velocity and distensibility.

“We know that abnormalities in the large vessels around the heart, the aorta and its primary branches, begin to develop in early childhood in people with Type 1 diabetes,” said lead study author Michal Schäfer, PhD, a researcher and fourth-year medical student at the University of Colorado School of Medicine, 

. “We found that bromocriptine has the potential to slow down the development of those abnormalities and decrease the risk for cardiovascular disease in this population.”

Named the Bromocriptine Quick Release T1D study (BCQR-T1D), the placebo-controlled, random-order, double-blinded, cross-over study, was launched by investigators from the University of Colorado School of Medicine spurred by the recent approval of bromocriptine quick release formulation for people with type 2 diabetes. With this in mind, the study, which was funded by the NIH and is purported to be the first study to examine the effect of bromocriptine quick release versus placebo therapy on arterial health in a type 1 diabetes population, randomized patients with type 1 diabetes to either an 0.8 mg dose or identical placebo tablets.

Of note, previous data from the study demonstrated use of bromocriptine was not associated with significant changes in most measures of glycemic control in youth or adults with type 1 diabetes, but was associated with increased serum creatinine and lowered blood pressure in youth with type 1 diabetes.

In the current study, investigators sought to examine the effects on central and peripheral vasculature, through an analysis of measurements of endothelial function and central and peripheral arterial stiffness from baseline and following the study’s intervention period. Investigators pointed out inclusion criterion for the study called for all participants to be 12-21 years of age, have type 1 diabetes for at least 1 year, and have an HbA1c equal to or less than 12%.

The study protocol included 2 phases. During the first phase, the randomly assigned intervention was administered for 4 weeks, after which the team performed measurements of pulse wave velocity, relative area change, and distensibility from phase-contrast magnetic resonance imaging. Following a 4-week washout period, phase 2 of study followed an identical fashion with the alternate treatment. Overall, the trial enrolled 34 adolescents with a mean age of 15.9 (SD, 2.6) years, a mean HbA1c of 8.6% (SD, 1.1), a mean BMI percentile of 71.4 (SD, 26.1), and a mean disease duration of 5.8 years.

Upon analysis, results of the study demonstrated use of bromocriptine quick release formulation was associated with greater decreases in systolic (∆=−5 mmHg [95% CI, −3 to −7]; 

<.001) and diastolic blood pressure (∆=−2 mmHg [95% CI, −4 to 0]; 

=.039). Analysis of secondary endpoints of interest suggested use of bromocriptine quick release formulation was also associated with a greater reduction in ascending aortic pulse wave velocity (∆=−0.4 m/s; 

=.018), increased relative area change (∆=−2.6%; 

=0.083), and distensibility (∆=0.08%/mmHg; 

=.017). Further analysis of MRI data from this cohort indicated bromocriptine quick release decreased pulse wave velocity (∆=−0.2 m/s; 

=0.007) and increased distensibility (∆=0.05 %/mmHg; 

=.013) in the thoraco-abdominal aorta compared to placebo.

“A stiff aorta predisposes a patient to other health issues, such as organ dysfunction or atherosclerosis and higher stress or strain on cardiac muscle,” Schäfer said. “We were able to take it a notch further and show, using more sophisticated metrics, that these central large arteries are impaired, and impairment among adolescents and young adults with type 1 diabetes may be decelerated with this drug.”

Bromocriptine Improves Central Aortic Stiffness in Adolescents With Type 1 Diabetes: Arterial Health Results From the BCQR-T1D Study

Data from the BCQR-T1D study, which was funded by the National Institutes of Health, suggest use of the dopamine receptor agonist bromocriptine was associated with improved blood pressure and arterial stiffness after 4 weeks of treatment in youth with type 1 diabetes.

Parkinson Disease Treatment, Bromocriptine, Could Reduce Arterial Stiffness, Blood Pressure in Pediatric T1D

A patient in their mid-70s presents to the hospital with lightheadedness that came on gradually during brunch with family. She checked her blood pressure and noted her heart rate was in the 30s. She didn’t feel that bad, so she waited a few hours, but it was the same so the family called 911. She denies syncope, palpitations, chest pain, SOB, leg swelling or pain, fever, cough or other complaints. She recently started Eliquis, metoprolol, and Pacerone for atrial flutter.

Vital signs are normal except for a pulse in the 30s. The physical exam is otherwise normal.

: Undetermined rhythm, rate 37, ST & T wave abnormality, consider lateral ischemia

Our latest case report features a woman in her mid-70s presenting to the hospital with lightheadedness that came on gradually during brunch. Check out the ECG and determine the correct diagnosis!

Cardiology Case Report: Brady Bunch

Cardiovascular disease (CVD) remains the leading killer of both men and women across the world. While marquee risk factors such as hypertension, diabetes, and obesity enjoy entire disciplines of medicine there exists a multitude of other factors that contribute to long-term CV risk. 

Everyone knows how important sleep is. So much so that there are entire industries dedicated to facilitating our nightly quest for rest. Emerging evidence suggests that sleep patterns and disturbances may play a significant role in our long-term cardiovascular health as well.

Although there are quite a few sleep disorders, obstructive sleep apnea (OSA) is ubiquitous today with widespread obesity contributing to the disease burden significantly. It is estimated that nearly 1 billion people are affected by OSA worldwide.

 Sleep apnea is closely associated with the obesity hypoventilation syndrome marked by retained carbon dioxide and hypertension as well as cardiovascular disease.

 More recently OSA has been linked to coronary artery disease, stroke, and heart failure.

In addition to sleep apnea, researchers have identified other sleep disturbances that contribute to CVD. A reduction in slow wave sleep (SWS) appears associated with OSA and is independently related to increased sympathetic activity which in turn increases the risk of cardiovascular and metabolic diseases.

 In essence, lack of slow wave sleep, or deep sleep, leads to cardiovascular stress and risk.

In addition to the quality of sleep, the duration of sleep appears to play a role in CV risk as well. Evidence suggests that those who sleep too little and those who sleep too much have higher rates of CVD.1 In particular, sleep durations less than 6 hours and greater than 10 were associated with increased rates of hypertension.1

Ultimately, the quality and duration of sleep are closely linked. Factors such as diet, stress, alcohol intake, and body composition are important in determining how much restful sleep each of us gets. Sleep apnea represents a cluster of symptoms and sequelae that affect several body systems. Through obstruction, usually due to excessive soft tissue in the mouth and neck, hypoventilation, increased CO2, and increased blood acid leads to changes in cardiovascular set points. Blood pressure and blood glucose levels rise leading to microvascular damage and cardiovascular disease.

The US Preventative Services Task Force thought the problem of OSA severe enough to put forth a set of recommendations this year.

 The task force recommends that positive airway pressure devices be employed when indicated for OSA.

They further recommend screening in an effort to increase early detection and treatment.

 As with most conditions, especially ones that lead to cardiovascular disease, the earlier in the disease process treatment is started, the slower the progression to overt complications.

Sleep medicine is a discipline whose time has come. We are seeing clinicians from multiple disciplines choosing to enter this specialized field highlighting its newfound importance. In any case these reports shed important light on the link between healthy sleep and a healthy cardiovascular system. OSA, hypertension, daytime fatigue, and poor sleep go hand in hand. We now know that good sleep may just mean a healthier heart in the long run. As clinicians, especially primary care providers, we should screen our at-risk patients at every opportunity for sleep disturbances. Now, with an increasing number of clinicians choosing sleep medicine as a specialty, patients can get the help they need in finding that perfect nightly slumber, and just maybe a healthier cardiovascular system.

Han, H., Wang, Y. Zong, G., et al. Sleep duration and risks of incident cardiovascular disease and mortality amoung people with type 2 diabetes. Front. Cardiovasc. Med., 31 October 2022 

https://doi.org/10.3389/fcvm.2022.1034785

US Preventive Services Task Force. Screening for Obstructive Sleep Apnea in Adults: US Preventive Services Task Force Recommendation Statement. 

 2022;328(19):1945–1950. doi:10.1001/jama.2022.20304

Gregory Weiss, MD, provides insight into his perspective on the evolving recognition of the role of sleep health in cardiovascular disease prevention. 

Putting the Debate to Rest: Recognizing the Role of Sleep in Cardiovascular Health, with Gregory Weiss, MD

The latest data release from Penn Medicine’s Nudge Unit is suggests nudges to primary care clinicians was associated with increased initiation of a 

A cluster randomized trial assessing use of electronic prompts for clinicians and patients suggests EHR nudges delivered to clinicians were effective for increasing statin prescription rates in primary care settings with or without a patient nudge, while patient nudges, which were delivered via text message, were found to be ineffective when used alone.

“To our knowledge, this study is one of the largest clinical trials testing nudges to clinicians and patients. Because these interventions were automated through the EHR, they provide a scalable template that can be used by health systems more broadly to improve patient care,” wrote investigators.

As technology has advanced, optimizing use of these new technologies in care has become a focus for millions within the healthcare community. This extensive research commitment has culminated in the creation of groups like the Nudge Unit at Penn Medicine. Billed as the world’s first behavioral design team embedded within a health system, the Nudge Unit hopes to leverage insights auto des, implement, and assess scalable electronic prompt programs aimed at improving patient outcomes.

Led by Srinath Adusumalli, MD, MSHP, MBMI, the deputy director at the Penn Medicine Nudge Unit, the current trial was designed as a cluster randomized clinical trial and included 4131 patients from 28 primary care practices urban and suburban Pennsylvania and New Jersey. The 4131 patients were randomized in a 1:1:1:1 ratio to a usual care group,a patient nudge group, a clinician nudge arm, and a combined nudge group.

The trial itself included a 12-month preintervention period and a 6-month intervention period. The preintervention period was used to identify clinicians who treated fewer than 10 patients eligible for a new statin prescription during the 12 months preceding the trial.

Statins were prescribed to 5.6% of patients in the usual care group, 4.8% in the patient nudge group, 6.0% in the clinician nudge group, and 4.7% in the combined group during the preintervention period. Investigators pointed out the overall study cohort had a mean age of 65.5 (SD, 10.5) years, 51.3% were male, 29.3% were Black, 2.6% were Hispanic, and 66.1% were White. At baseline, 22.6% (n=933) had atherosclerotic cardiovascular disease.

Results of the investigators’ analysis suggested statins were prescribed to 7.3% of patients in the usual care group, 8.5% in the patient nudge group, 13.0% in the clinician nudge arm, and 15.5% in the combined group during the intervention period of the trial. In adjusted analyses comparing nudges against usual care, results indicated clinician nudges were associated with significantly increased statin prescribing alone (5.5 percentage points [95% CI, 3.4 to 7.8]; 

 = .01) and when combined with the patient nudge (7.2 percentage points [95% CI, 5.1 to 9.1]; 

=.001). In contrast, patient nudges alone did not significantly increase statin prescribing relative to usual care (0.9 percentage points [95% CI, −0.8 to 2.5]; 

, Faraz S. Ahmad, MD, MS, and Stephen D. Persell, MD, both of Northwestern University, commended investigators for their trial and the insights provided but also cautioned against overinterpretation of results, specifically the effectiveness of clinician-directed nudges versus patient-directed nudges.

“We commend the authors for this rigorous, pragmatic study testing clinician and patient nudges embedded into routine care of patients in primary care clinics and conducted under a waiver of consent for clinicians and patients. The capability to rapidly conduct pragmatic trials like this comprises an essential component of learning health systems for cardiovascular care,” wrote the pair.

Effect of Nudges to Clinicians, Patients, or Both to Increase Statin Prescribing

A cluster randomized trial from Penn Medicine's Nudge Unit provides insight into the effects of "nudges" in primary care settings for improving the prescription of statins. 

Timely EHR Nudges Linked to Increased Statin Prescription in Primary Care Settings

Data from the DASH trial provides evidence demonstrating adherence to a healthy diet can reduce cardiovascular disease risk by 10% in adult patients.

An analysis of data from the landmark trial led by investigators at Beth Israel Deaconess Medical Center (BIDMC), results of the study suggest adherence to the DASH diet was associated with a 10.3% reduction in 10-year ASCVD risk and adherence to the fruit and vegetable diet was associated with a 9.9% reduction in 10-year risk compared to the Western diet over an 8-week period, with these effects more apparent in women and Black adults.

"While physicians and patients rely on the extensive data available when choosing appropriate pharmacologic therapy to prevent atherosclerotic cardiovascular disease, there's limited evidence to inform expectations for risk reductions from established lifestyle interventions," said study investigator Stephen P. Jurashcek, MD, PhD, a clinician-researcher in the Department of Medicine at BIDMC, 

 "Our study suggests that the benefits associated with these diets may vary by sex and race. While a diet rich in fruits and vegetables produced reductions in risk for woman and Black participants, the effect with the DASH diet was twice as large in women and 4 times as large in Black adults."

As a result of the limited evidence related to nutrition and cardiovascular health, the NHLBI-sponsored Dietary Approaches to Stop Hypertension (DASH) trial was an endeavor launched in 1993 with the aim of evaluating the effects of different dietary approaches for lowering blood pressure. With randomization beginning in 1994, the multicenter trial randomized patients to 1 of 3 dietary approaches: a typical “Western” diet, a diet heavy in fruit and vegetables, or the DASH diet, which was characterized as being high in fruits, vegetables, and low-fat dairy products, and had a favorable macronutrient profile.

in 1997, the original article demonstrated adherence to the DASH diet reduced systolic and diastolic blood pressure by 5.5 and 3.0 mmHg more, respectively, than the control diet (

<.001 for each). Results also indicated adherence to the fruits and vegetables diet was associated with a systolic blood pressure reduction 2.8 mmHg greater (

 <.001) and diastolic blood pressure reduction 1.1 mmHg greater (

In the current analysis, investigators leveraged data from the trial to determine the effects of each approach on 10-year ASCVD risk score using information related to blood pressure and lipid measurements before and after the 8-week intervention period.

Upon analysis, results indicated adherence to the DASH diet during the trial was associated with a -10.3% (95% CI, -14.4 to -5.9) reduction in 10-year ASCVD risk score, with this effect more pronounced in women and Black adults. Adherence to the fruits and vegetables diet was associated with a -9.9% (95% CI, -14.0 to -5.5) reduction in 10-year ASCVD risk score, with the trend of a more pronounced effect seen in women and Black adults also observed among this cohort. Comparisons of the DASH diet against the fruits and vegetable diet demonstrated there were no significant differences between the approaches (-0.4% [95% CI, -6.9 to 6.5]).

Further analysis suggested the reductions in risk observed attributable to the difference in systolic blood pressure alone, relative to the control diet, were -14.6% (95% CI, -17.3 to -11.7) with the DASH diet and -7.9% (95% CI, -10.9 to -4.8) with the fruits and vegetables diet, with a net relative advantage of 7.2% greater relative reduction favoring the DASH diet compared to the fruits and vegetables diet. However, investigators pointed out this reduction was offset by the impact of the DASH diet on high-density lipoprotein, which increased 10-year risk score by 8.8% (95% CI, 5.5 to 12.3) versus the more neutral effect of -1.9% (95% CI, -5.0 to 1.2) observed with the fruits and vegetables diet.

"The findings could have major implications for clinical practitioners and policy makers alike," said lead investigator Sun Young Jeong, MD, MPH, an internal medicine resident at BIDMC, in the aforementioned statement. "Cardiovascular disease is the leading cause of death in women and hypertension is also more strongly linked with heart failure and death in women than men. We also know women are less likely to receive risk factor modification therapies, such as statins, so our finding that DASH may be more efficacious among women are relevant for lifestyle counseling in this group."

Effects of Diet on 10-Year Atherosclerotic Cardiovascular Disease Risk (from the DASH Trial)

Leveraging data from the DASH trial, investigators from Beth Israel Deaconess Medical Center provides insight into the impact of different dietary approaches on 10-year ASCVD risk score among patients within the trial.

Study Shows Proper Diet Could Reduce Cardiovascular Risk by 10% or More

Encouraging patients to be more cognizant of the amount of salt they are adding to their food could have a dramatic effect on risk of cardiovascular disease, according to a new analysis of the UK Biobank cohort.

An analysis of data from more than 175,000 adults with food frequency questionnaire response information and no history of cardiovascular disease prior to enrollment, results suggest those reporting usually, sometimes, and never/rarely adding salt to their food had 19%, 21%, and 23% reductions, respectively, in risk of incident cardiovascular disease events compared to their counterparts who reported always adding salt to their food.

“Overall, we found that people who don’t shake on a little additional salt to their foods very often had a much lower risk of heart disease events, regardless of lifestyle factors and pre-existing disease,” said Lu Qi, MD, PhD, HCA Regents Distinguished Chair and professor at the School of Public Health and Tropical Medicine at Tulane University, in 

a statement from the American College of Cardiology

. “We also found that when patients combine a DASH diet with a low frequency of adding salt, they had the lowest heart disease risk. This is meaningful as reducing additional salt to food, not removing salt entirely, is an incredibly modifiable risk factor that we can hopefully encourage our patients to make without much sacrifice.”

In the wake of the Salt Substitute and Stroke Study outlining the effects of reducing overall sodium intake on cardiovascular event risk, the current study was conducted by Qi, along with a team colleagues from Tulane University, with the intent of assessing whether the frequency of adding salt to foods is associated with cardiovascular disease risk in prospective cohorts, which investigators noted would be the first time this association was examined in this manner. Using the UK Biobank cohort, which is a large population-based, prospective study including more than 500,000 participants aged 37-73 years recruited from 2006-2010, investigators obtained data related to a cohort of 210,999 participants who completed at least 1 web-based 24-hour dietary assessment from 2009-2012.

From this cohort, investigators excluded an additional 34,429 individuals for having incomplete data on frequency of adding salt to foods, having implausible total energy intake, having a history of cardiovascular disease before the last diet assessment, and indicating their diet for that day was not typical. As a result, the final analytical cohort included 176,570 individuals with a median follow-up of 11.8 years. During this time, 9,963 total cardiovascular disease events, 6,993 ischemic heart disease cases, 2,007 stroke cases, and 2,269 heart failure cases were documented among the study cohort.

As part of the UK Biobank study, participants took part in baseline questionnaires assessing the frequency of adding salt to foods, not including adding salt in the process of cooking, with 5 potential answers: never/rarely, sometimes, usually, always, or prefer not to answer. For the purpose of analysis, investigators used a modified DASH diet score to evaluate the dietary assessments completed from 2009-2012, with the scoring system based on quintiles, with the lowest intake quintile receiving 1 point and the top quintile receiving 5 points for healthy components.

When assessing differences in risk factors and characteristics among individuals reporting lower or greater frequency of adding salt to foods, investigators found those with a lower frequency were more likely to be women, white, have a lower body mass index, have moderate alcohol consumption, and report more physical activity. These individuals were also more likely to adhere to a DASH-style diet.

In analyses adjusted for covariates and the modified DASH diet score, lower frequency of adding salt to foods was associated with a significantly lower risk of total cardiovascular disease events. For incident cardiovascular disease events, those reporting the usually, sometimes, and never/rarely adding salt to food experienced relative risk reductions of 19% (aHR, 0.81 [95% CI, 0.73-0.90]), 21% (aHR, 0.79 [95% CI, 0.71-0.87]), and 23% (aHR, 0.77 [95% CI, 0.70-0.84]), respectively, for cardiovascular disease compared to their counterparts reporting always adding salt to food (P <.001).

Further analysis examining different subtypes of cardiovascular disease demonstrated the strongest association was observed with incident heart failure (P <.001), followed by incident ischemic heart disease (P <.001), but no association was observed for risk of stroke. Investigators noted the lowest cardiovascular disease risk was observed among individuals who combined a DASH-style diet with the lowest frequency of adding salt to food.

Investigators cautioned clinicians to consider the limitations of their study before overinterpretation of results and suggested randomized trials were needed to verify results. Specific limitations noted by investigators included reliance on self-reported data and the observational nature of the study creating the possibility of residual or unmeasured confounding.

Adding Salt to Foods and Risk of Cardiovascular Disease

An analysis of self-reported dietary information from UK Biobank participants is providing insight into the effects of reducing added salt to foods on cardiovascular disease risk among adults without a history cardiovascular disease.

Holding Back on Adding Salt to Food Linked to Reduced Cardiovascular Risk

A patient in their mid-70s with a history of hypertension is brought in by medics for chest pain with onset about 45 minutes prior to arrival while he was getting dressed. His chest pain radiates to both shoulders and is associated with nausea and mild shortness of breath. He denies vomiting, dizziness or lightheadedness. He notes that he had an episode of similar pain yesterday afternoon which lasted about 20 minutes and then resolved spontaneously after he lay down. He has no known cardiac history.

Vital signs are normal. The physical exam is also normal.

Computer Read: Sinus rhythm with marked sinus arrhythmia, RBBB

This case report features a patient in their mid-70s with a history of hypertension is brought in with chest pain radiating to both shoulders along with nausea and mild shortness of breath. Check out the full case report and determine the correct diagnosis!

Case Report: Bilateral = Beware!

The last weekend of each month, our editorial team compiles a list of our most popular cardiology content from the past month for a month in review recap. The November 2022 cardiology month in review features the top content from AHA Scientific Sessions 2022, new data related to use of direct oral anticoagulation, and an FDA warning to companies over violations of the FD&C Act.

Each year, the American Heart Association Scientific Sessions serves as the year’s final showcase for advances and updates in the world of cardiovascular and cardiometabolic health. the AHA Scientific Sessions 2022 was the first in-person iteration of the AHA’s annual meeting since 2019 and was held in Chicago, Il from November 4-7, 2022. While on-site at the meeting, our editorial team brought our audience up to the minute coverage of late breaking sessions and other presentations from the meeting, including interviews with key opinion and trial leaders. For the month in review, we are highlighting the 3 most popular pieces of content from the past month related the AHA Scientific Sessions 2022, which includes the STRONG-HF trial, RESPECT-EPA, OCEAN(a)-DOSE, and our AHA Highlights recap.

STRONG-HF: In-Hospital Initiation of GDMT Reduces Rehospitalization, Mortality Risk in Heart Failure Patients

Results of the STRONG-HF trial provide the first evidence from a randomized clinical trial that rapid, in-hospital initiation of guideline-directed medical therapy in heart failure can improve patient outcomes.

EPA Reaches Borderline Statistical Significance in RESPECT-EPA Trial

The November 2022 cardiology month in review features the top content from AHA Scientific Sessions 2022, new data related to use of direct oral anticoagulation, and an FDA warning to companies over violations of the FD&C Act.