Cardiovascular Disease Risk in Young People with Type 1 Diabetes

Cardiovascular disease (CVD) is the most frequent cause of death in people with type 1 diabetes (T1D), despite modern advances in glycemic control and CVD risk factor modification. CVD risk identification is essential in this high-risk population, yet remains poorly understood. This review discusses the risk factors for CVD in young people with T1D, including hyperglycemia, traditional CVD risk factors (dyslipidemia, smoking, physical activity, hypertension), as well as novel risk factors such as insulin resistance, inflammation, and hypoglycemia. We present evidence that adverse changes in cardiovascular function, arterial compliance, and atherosclerosis are present even during adolescence in people with T1D, highlighting the need for earlier intervention. The methods for investigating cardiovascular risk are discussed and reviewed. Finally, we discuss the observational studies and clinical trials which have thus far attempted to elucidate the best targets for early intervention in order to reduce the burden of CVD in people with T1D.     

Sex Difference in the Association between Lipid Profile and Incident Cardiovascular Disease among Young Adults

Aim: Using a nationwide epidemiological database, we sought to examine whether there was a sex difference in the association between lipid profiles and subsequent cardiovascular disease (CVD) in young adults. Methods: Medical records of 1,909,362 young adults (20–49 years old) without a prior history of CVD and not taking lipid-lowering medications were extracted. We conducted multivariable Cox regression analyses to identify the association between the number of abnormal lipid profiles and incident CVD. Results: After a mean follow-up of 3.4±2.6 years, myocardial infarction (MI), angina pectoris (AP), stroke, and heart failure (HF) developed in 2,575 (0.1%), 26,006 (1.4%), 10,748 (0.6%), and 24,875 (1.3%) subjects, respectively. The incidence of MI, AP, and HF increased with the number of abnormal lipid profiles in both men and women, whereas the incidence of stroke increased with the number of abnormal lipid profiles only in men but not in women. Multivariable adjusted hazard ratios (HRs) for MI per 1-point higher abnormal lipid profile were 1.57 (95% confidence interval [CI] 1.49–1.65) in men and 1.25 (95% CI 1.07–1.47) in women. HRs for AP, stroke, and HF per 1-point higher abnormal lipid profile were 1.14 (95% CI 1.12–1.16), 1.06 (95% CI 1.02–1.09), and 1.10 (95% CI 1.08–1.12) in men and 1.18 (95% CI 1.13–1.23), 1.09 (95% CI 1.03–1.16), and 1.10 (95% CI 1.05–1.14) in women. Conclusion: Our analysis demonstrated an association between the number of abnormal lipid profiles and incident CVD in both men and women. The association between the number of abnormal lipid profiles and incident MI was pronounced in men.     

顺德勒流地区适龄应征参军男青年心血管病发生率及相关因素的调查

目的了解顺德勒流地区应征参军男青年心血管疾病的发病情况及其相关因素。方法2001年-2005年应征男性青年共1947人．对其进行征兵体检以及生活方式的问卷调查。结果2001年-2005年高血压病、肥胖、心律失常的发生率分别为0．25％～2．76％、1．26％～4．52％．2．27％～5．78％．有逐年增多的趋势，而先天性心脏病则无增加倾向。结论男性青年生活及工作方式有较大的转变。嗜烟、嗜酒及过多的夜生活，玩电脑、游戏机较易引起高血压病、心律失常，而嗜酒、不合理饮食、运动少较易出现肥胖。     

Non-Atherosclerotic Vascular Disease in the Young

There are a large variety of non-atherosclerotic causes of ischemic stroke in the young. Arterial dissection, most commonly associated with non-traumatic causes, is among the most common. Both the carotid and vertebrobasilar circulations can be affected. The vasculitidies represent a rare, but potentially treatable series of conditions that can lead to stroke through diverse mechanisms. Moyamoya is a nonatherosclerotic, noninflammatory, nonamyloid vasculopathy characterized by chronic progressive stenosis or occlusion of the distal internal carotid arteries and/or proximal portions of the middle and/or anterior cerebral arteries. Moyamoya can be idiopathic (moyamoya disease) or the result of other conditions. An appreciation of the unusual causes of stroke in the young is important when considering secondary prevention measures.     

Epithelial Sodium Channel Inhibition by Amiloride on Blood Pressure and Cardiovascular Disease Risk in Young Prehypertensives

Overactivity of the epithelial sodium channel (ENaC) is considered to be one mechanism underlying obesity‐related blood pressure (BP) elevation. In an open‐labeled, nonplacebo‐controlled clinical trial (Clinicaltrials.gov: NCT‐01308983), the authors aimed to comprehensively evaluate the effects of amiloride monotherapy, an ENaC blocker, on BP and cardiovascular risk in young adults with prehypertension (n=17). The mean body mass index of participants was 28.45±1.30 kg/m². Following 10 mg daily amiloride for 4 weeks, peripheral systolic BP (SBP), central SBP, and carotid‐radial pulse wave velocity were significantly reduced by −7.06±2.25 mm Hg, −7.68±2.56 mm Hg, and −0.72±0.33 m/s, respectively, whereas flow‐mediated dilation was significantly increased by 2.2±0.9%. Following amiloride monotherapy for 4 weeks, a significant increase in serum aldosterone was observed (5.85±2.45 ng/dL). ENaC inhibition by amiloride may be used as an early intervention to halt the progression to full hypertension and cardiovascular disease in young adults with prehypertension.

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) introduced the new term prehypertension for adults with systolic blood pressure (SBP) of 120 mm Hg to 139 mm Hg and/or diastolic blood pressure (DBP) of 80 mm Hg to 89 mm Hg to recognize the negative impact of BP elevation on cardiovascular disease (CVD) risk.¹ Utilizing the National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2006, Gupta and colleagues² reported the prevalence of prehypertension in disease‐free adults to be 36.3%. It is estimated that approximately 40% of individuals with prehypertension progress to hypertension within 2 years.³ As such, it is critical to intervene early to stop the progression of prehypertension to hypertension, and hypertension to complicated hypertension later in life.The JNC 7 recommends a lifestyle modification approach including weight loss, dietary changes, and regular aerobic exercise for the treatment of prehypertension. In fact, several randomized controlled trials have demonstrated the effectiveness of weight loss and dietary changes. Specifically, reductions in sodium intake and increased consumption of fruits and vegetables, ie, adoption of the Dietary Approaches to Stop Hypertension (DASH) diet, have been shown to lower BP over time and thus reduce the future risk of hypertension and CVD.⁴, ⁵, ⁶ However, the effectiveness of these lifestyle interventions has been inconsistent outside of the controlled environment of clinical trials.⁷ There was low accordance with DASH dietary pattern among adults with known hypertension in the United States,⁸ suggesting that lifestyle modification is not only hard to adopt, but also difficult to develop into habits in daily life. To date, two clinical trials using pharmacologic interventions have shown benefits of preventing and/or delaying de novo hypertension in individuals with prehypertension. Julius and colleagues³ showed a 66% relative risk reduction in the incidence of new‐onset hypertension following 2 years of treatment with the angiotensin receptor blocker (ARB) candesartan as compared with placebo in adults with prehypertension. Using a similar pharmacologic approach, Luders and colleagues⁹ reported a 34% relative risk reduction after 3 years in the development of hypertension in prehypertensive patients who were randomly assigned to take an angiotensin‐converting enzyme (ACE) inhibitor, ramipril, vs patients assigned to placebo.Amiloride, a well‐tolerated potassium‐sparing diuretic, blocks the epithelial sodium channel (ENaC). ENaC, comprised of α, β, and γ subunits and primarily expressed on the apical membrane of epithelial cells in the renal cortical collecting duct, is known to play an important role in BP homeostasis.¹⁰, ¹¹, ¹² A clinical trial evaluating the usefulness of pharmacologic intervention using diuretics, chlorthalidone plus amiloride, in individuals with prehypertension to reduce incidence of hypertension and adverse CV events is currently underway in Brazil.⁷ In the clinical trial, amiloride (2.5 mg/d) is used to prevent the deleterious hypokalemia induced by chlorthalidone. However, the effects of pharmacologic blockade of ENaC by amiloride as monotherapy remain unknown in individuals with prehypertension.Accumulating evidence indicates that central BP, measured noninvasively, may be a stronger and more accurate predictor of future CV events than peripheral BP.¹³, ¹⁴ Brachial artery flow‐mediated dilation (FMD) has been recognized as a valid and reliable noninvasive biomarker of nitric oxide–dependent vasodilation and endothelial function.¹⁵ Pulse wave velocity (PWV) is a noninvasive surrogate marker of arterial stiffness.¹⁶ In the present study, we aimed to investigate the effects of amiloride monotherapy on peripheral and central BP as well as on CVD risk including FMD and PWV in drug‐naive African American and Caucasian adults with prehypertension.     

Aspirin for the Primary Prevention of Cardiovascular Disease in Women

Primary prevention of cardiovascular disease, which is the leading cause of death of women in the United States, focuses on treating or eliminating risk factors and often includes the use of aspirin to prevent thrombotic complications of atherosclerosis or atrial fibrillation. Recent evidence reveals sex-based differences in the benefits of aspirin in individuals without established cardiovascular disease. Although use of aspirin does not affect total mortality in either sex, aspirin lowers the risk of ischemic stroke in women and decreases the risk of myocardial infarction in men. Unfortunately, the use of aspirin comes at the expense of an increase in bleeding events, mostly gastrointestinal, that occurs at roughly similar rates in women and men. Aspirin may not be beneficial for primary prevention of cardiovascular events in women with diabetes. The benefits, as well as the risks, of aspirin therapy should be discussed when contemplating the use of aspirin in the primary prevention of cardiovascular disease in women.     

Incidence of Atherosclerotic Cardiovascular Disease in Young Adults at Low Short-Term But High Long-Term Risk

BackgroundYoung adults may have high long-term atherosclerotic cardiovascular disease (ASCVD) risk despite low short-term risk.ObjectivesIn this study, we sought to compare the performance of short-term and long-term ASCVD risk prediction tools in young adults and evaluate ASCVD incidence associated with predicted short-term and long-term risk.MethodsWe included adults aged 18 to 39 years, from 2008 to 2009 in a U.S. integrated health care system, and followed them through 2019. We calculated 10-year and 30-year ASCVD predicted risk and assessed ASCVD incidence.ResultsAmong 414,260 young adults, 813 had an incident ASCVD event during a median of 4 years (maximum 11 years). Compared with 10-year predicted risk, 30-year predicted risk improved reclassification (net reclassification index: 16%) despite having similar discrimination (Harrell’s C: 0.749 vs 0.726). Overall, 1.0% and 2.2% of young adults were categorized as having elevated 10-year (≥7.5%) and elevated 30-year (≥20%) predicted risk, respectively, and 1.6% as having low 10-year (<7.5%) but elevated 30-year predicted risk. The ASCVD incidence rate per 1,000 person-years was 2.60 (95% CI: 1.92-3.52) for those with elevated 10-year predicted risk, 1.87 (95% CI: 1.42-2.46) for those with low 10-year but elevated 30-year predicted risk, and 0.32 (95% CI: 0.30-0.35) for those with low 10-year and 30-year predicted risk. The age- and sex-adjusted incidence rate ratio was 3.04 (95% CI: 2.25-4.10) comparing those with low 10-year but elevated 30-year predicted risk and those with low 10-year and 30-year predicted risk.ConclusionsLong-term ASCVD risk prediction tools further discriminate a subgroup of young adults with elevated observed risk despite low estimated short-term risk.     

多层螺旋CT在心血管疾病中的应用进展

多层螺旋CT的发明是CT发展史上的一大飞跃,为CT在诊断、治疗冠状动脉粥样硬化性心脏病等心血管疾病中的应用带来了新的机遇,提供了无创的简易方法。多层螺旋CT在诊断冠状动脉粥样硬化性心脏病、主动脉夹层、心功能测定、肺栓塞、评估心房颤动射频消融术前及脑血管成像、肾动脉成像等方面发挥着越来越重要作用。     

2021 Canadian Cardiovascular Society Guidelines for the Management of Dyslipidemia for the Prevention of Cardiovascular Disease in Adults

The 2021 guidelines primary panel selected clinically relevant questions and produced updated recommendations, on the basis of important new findings that have emerged since the 2016 guidelines. In patients with clinical atherosclerosis, abdominal aortic aneurysm, most patients with diabetes or chronic kidney disease, and those with low-density lipoprotein cholesterol ≥ 5 mmol/L, statin therapy continues to be recommended. We have introduced the concept of lipid/lipoprotein treatment thresholds for intensifying lipid-lowering therapy with nonstatin agents, and have identified the secondary prevention patients who have been shown to derive the largest benefit from intensification of therapy with these agents. For all other patients, we emphasize risk assessment linked to lipid/lipoprotein evaluation to optimize clinical decision-making. Lipoprotein(a) measurement is now recommended once in a patient's lifetime, as part of initial lipid screening to assess cardiovascular risk. For any patient with triglycerides ˃ 1.5 mmol/L, either non-high-density lipoprotein cholesterol or apolipoprotein B are the preferred lipid parameter for screening, rather than low-density lipoprotein cholesterol. We provide updated recommendations regarding the role of coronary artery calcium scoring as a clinical decision tool to aid the decision to initiate statin therapy. There are new recommendations on the preventative care of women with hypertensive disorders of pregnancy. Health behaviour modification, including regular exercise and a heart-healthy diet, remain the cornerstone of cardiovascular disease prevention. These guidelines are intended to provide a platform for meaningful conversation and shared-decision making between patient and care provider, so that individual decisions can be made for risk screening, assessment, and treatment.