Seasonal and Geographic Patterns in Seeking Cardiovascular Health Information: An Analysis of the Online Search Trends

Objective

To ascertain whether temporal and geographic interest in seeking cardiovascular disease (CVD) information online follows seasonal and geographic patterns similar to those observed in real-world data.

Exercise Counteracts the Cardiotoxicity of Psychosocial Stress

Physical inactivity and psychosocial stress are prevalent in residents of the United States. The purpose of this article is to review the interaction between these 2 conditions and examine the effects of exercise on stress and cardiovascular (CV) health. A query of scientific references between 1974 to 2018 was performed using the PubMed search engine accessing the MEDLINE database using the search terms psychosocial stress, CV disease (CVD), physical activity, exercise, cardiac rehabilitation, and team sports. Psychosocial stress is a strong independent risk factor for adverse CV events. Conversely, people who experience CV events subsequently have drastically elevated rates of new-onset mental health disorders, including depression and anxiety. Psychosocial stress and CVD often trigger self-reinforcing feedback loops that can worsen mental health and cardiac prognosis. Exercise predictably improves CV health and prognosis and also is effective at lowering levels of psychosocial stress. Group exercise in particular seems to provide social support while at the same time boosting fitness levels and, thus, may be the single most important intervention for patients with concomitant CVD and emotional stress. Collaborative physical activity, such as group exercise, team sports, interactive physical play, and cardiac rehabilitation programs, have the potential to improve mental health and CV prognosis.     

Perceived Discrimination and Cardiovascular Outcomes in Older African Americans: Insights From the Jackson Heart Study

Objective

To assess the associations of perceived discrimination and cardiovascular (CV) outcomes in African Americans (AAs) in the Jackson Heart Study.

Promoting Health and Wellness in the Workplace: A Unique Opportunity to Establish Primary and Extended Secondary Cardiovascular Risk Reduction Programs

Given the burden of cardiovascular disease (CVD), increasing the prevalence of healthy lifestyle choices is a global imperative. Currently, cardiac rehabilitation programs are a primary way that modifiable risk factors are addressed in the secondary prevention setting after a cardiovascular (CV) event/diagnosis. Even so, there is wide consensus that primary prevention of CVD is an effective and worthwhile pursuit. Moreover, continual engagement with individuals who have already been diagnosed as having CVD would be beneficial. Implementing health and wellness programs in the workplace allows for the opportunity to continually engage a group of individuals with the intent of effecting a positive and sustainable change in lifestyle choices. Current evidence indicates that health and wellness programs in the workplace provide numerous benefits with respect to altering CV risk factor profiles in apparently healthy individuals and in those at high risk for or already diagnosed as having CVD. This review presents the current body of evidence demonstrating the efficacy of worksite health and wellness programs and discusses key considerations for the development and implementation of such programs, whose primary intent is to reduce the incidence and prevalence of CVD and to prevent subsequent CV events. Supporting evidence for this review was obtained from PubMed, with no date limitations, using the following search terms: worksite health and wellness, employee health and wellness, employee health risk assessments, and return on investment. The choice of references to include in this review was based on study quality and relevance.     

Relationships between monocyte count to high-density lipoprotein cholesterol ratio and cardiovascular outcomes in patients commencing dialysis

ObjectiveHigh monocyte to high-density lipoprotein cholesterol ratio (MHR) is known to be a risk factor for cardiovascular (CV) complications. We aimed to evaluate the relationship between MHR and CV outcomes in patients commencing dialysis.MethodsThe medical records of patients who started maintenance dialysis between January 2006 and July 2017 were reviewed. The primary outcomes were all-cause mortality and overall CV mortality and the secondary outcomes were CV event-free survival and the incidence of CV complications.ResultsFive hundred ninety-seven patients were enrolled and allocated to low- or high-MHR groups. All-cause mortality did not differ between the groups during a mean follow-up period of 3.9 years. In addition, overall CV mortality did not differ between the groups. However, CV event-free survival was significantly lower in the high-MHR group than in the low-MHR group (47.5% vs. 59.0%). Multivariate Cox regression analysis showed that high MHR was an independent predictor of CV events (HR 1.886, 95% CI 1.015–3.505).ConclusionHigh MHR at the time of initiation of dialysis may represent a useful predictor of CV complications.     

Triptan Use as a Function of Cardiovascular Risk. A Population‐Based Study

(Headache 2010;50:256‐263) Aim.— To estimate the proportion of individuals with migraine using triptan therapy as a function of their cardiovascular (CV) profile and disease severity. Methods.— As a part of the American Migraine Prevalence and Prevention study, we identified migraineurs representative of the U.S. adult population. Triptan use was estimated as a function of presence of CV disease (CVD), of CV risk factors, and by level of migraine‐related disability. Results.— Our sample consists of 6102 individuals with migraine. Compared with migraineurs without risk factors for CVD, triptans were significantly less likely to be used in individuals with diabetes (11.5% vs 18.3%, OR = 0.6, 95% CI = 0.5‐0.7), hypertension (14.8%, OR = 0.8, 0.7‐0.9) and by smokers (12.9%, OR = 0.7, 0.6‐0.8). Similar findings were seen for individuals with established CVD. As contrasted to individuals without CVD, those with myocardial infarct (8.5% vs 18.5%, OR = 0.4, 0.3‐0.7), stroke (7%, OR = 0.6, 0.3‐0.9) and heart surgery (9.3%, OR = 0.5, 0.4‐0.7) were less likely to use triptans. Use of triptan increased as a function of disability regardless of CVD status or presence of CV risk factors. Conclusion.— Triptan use is lower in those with vs without CV risk, suggesting that doctors and/or patients fear using triptans in individuals at risk to CVD. Furthermore, triptan use in those with established CVD increases with headache‐related disability, suggesting that patients and providers balance risks and benefits. Additional and analytical data are needed on the safety of triptans in the setting of CVD risk. This study has not assessed adequacy of care.     

Association of Elevated Triglycerides With Increased Cardiovascular Risk and Direct Costs in Statin-Treated Patients

ObjectiveTo retrospectively investigate the real-world impact of elevated triglyceride (TG) levels on cardiovascular (CV) outcomes, medical resource utilization, and medical costs using observational administrative claims data from the Optum Research Database.MethodsPatients with one or more claims for statin therapy between January 1, 2010, and December 31, 2010, and 6 months or more of baseline data prior to the index date were eligible for inclusion in the study. Patients aged 45 years or older with diabetes and/or atherosclerotic CV disease were included and analyzed in an elevated TG cohort (≥150 mg/dL) vs a comparator cohort with TG levels less than 150 mg/dL and high-density lipoprotein cholesterol (HDL-C) levels greater than 40 mg/dL.ResultsIn the elevated TG vs propensity-matched comparator cohorts (both N=23,181 patients), the mean age was 62.2 vs 62.6 years, mean follow-up was 41.4 vs 42.5 months, 49.7% (11,518) vs 49.5% (11,467) were female, 83.7% (19,392) vs 84.0% (19,478) had diabetes, and 29.8% (6915) vs 29.3% (6800) had atherosclerotic CV disease. In the elevated TG (N=27,471 patients) vs comparator (N=32,506 patients) cohorts, multivariate analysis revealed significantly greater risk of composite major CV events (hazard ratio [HR], 1.26; 95% CI, 1.19-1.34; P<.001), nonfatal myocardial infarction (HR, 1.32; 95% CI, 1.20-1.45; P<.001), nonfatal stroke (HR, 1.14; 95% CI, 1.04-1.24; P=.004), and need for coronary revascularization (HR, 1.46; 95% CI, 1.33-1.61; P<.001) but not unstable angina (P=.53) or CV death (P=.23). Increased CV risk was maintained with the addition of non–HDL-C to the multivariate model and with high and low HDL-C subgroup analysis. Total direct health care costs (cost ratio, 1.12; 95% CI, 1.08-1.16; P<.001) and inpatient hospital stays (HR, 1.13; 95% CI, 1.10-1.17; P<.001) were significantly higher in the elevated TG cohort vs the comparator cohort.ConclusionStatin-treated patients with TG levels of 150 mg/dL or greater had worse CV and health economic outcomes than those with well-managed TG (<150 mg/dL) and HDL-C (>40 mg/dL) levels.     

BARI 2D: A Reanalysis Focusing on Cardiovascular Events

ObjectiveTo reanalyze the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial using a new composite cardiovascular disease (CVD) outcome to determine how best to treat patients with type 2 diabetes mellitus and stable coronary artery disease.Patients and MethodsFrom January 1, 2001, to November 30, 2008, 2368 patients with type 2 diabetes mellitus and angiographically proven coronary artery disease were randomly assigned to insulin-sensitizing (IS) or insulin-providing (IP) therapy and simultaneously to coronary revascularization (REV) or no or delayed REV (intensive medical therapy [MED]), with all patients receiving intensive medical treatment. The outcome of this analysis was a composite of 8 CVD events.ResultsFour-year Kaplan-Meier rates for the composite CVD outcome were 35.8% (95% CI, 33.1%-38.5%) with IS therapy and 41.6% (95% CI, 38.7%-44.5%) with IP therapy (P=.004). Much of this difference was associated with lower in-trial levels of fibrinogen, C-reactive protein, and hemoglobin A_1c with IS therapy. Four-year composite CVD rates were 32.7% (95% CI, 30.0%-35.4%) with REV and 44.7% (95% CI, 41.8%-47.6%) with MED (P<.001). A beneficial effect of IS vs IP therapy was present with REV (27.7%; 95% CI, 24.0%-31.4% vs 37.5%; 95% CI, 33.6%-41.4%; P<.001), but not with MED (43.6%; 95% CI, 39.5%-47.7% vs 45.7%; 95% CI, 41.6%-49.8%; P=.37) (homogeneity, P=.05). This interaction between IS therapy and REV was limited to participants preselected for coronary artery bypass grafting (CABG). The lowest composite CVD rates occurred in patients preselected for CABG and assigned to IS therapy and REV (17.3%; 95% CI, 11.8%-22.8%).ConclusionIn the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial, the IS treatment strategy and the REV treatment strategy each reduces cardiovascular events. The combination of IS drugs and CABG results in the lowest risk of subsequent CVD events.Trial Registrationclinicaltrials.gov Identifier: NCT00006305     

Towards Cardiovascular Health

This paper — in tribute to Martti Karvonen not only as researcher, teacher, organizer, friend, but also as statesman and strategist — focusses on several major contemporary strategic issues central for advancing cardiovascular health. These include:

1. the importance of the North Karelia Project emphasis on mass prevention in the community, for combatting the cardiovascular disease epidemic;

2. the extensive data base for the population-wide strategy for CVD prevention;

3. the important independent contribution of dietary lipid, particularly dietary cholesterol to cardiovascular disease risk;

4. the important role of diet — especially high dietary Na and high dietary Na/K, caloric imbalance with consequent obesity, and heavy alcohol intake — in the causation of the mass occurrence in the population of blood pressure levels above optimal and the frank hypertension;

5. the ability to improve population life styles and patterns of life-style-related risk factors;

6. the relation of improvements in life style and life-style-related risk factors, achieved to date in countries like Finland and the U.S.A., to the declines in cardiovascular disease mortality in these countries.     

American heart association’s cardiovascular health metrics and risk of cardiovascular disease mortality among a middle-aged male Scandinavian population

Abstract

Background: The burden of cardiovascular disease (CVD) prompted the American Heart Association to develop a cardiovascular health (CVH) metric as a measure to assess the cardiovascular status of the population. We aimed to assess the association between CVH scores and the risk of CVD mortality among a middle-aged Finnish population.

Methods: We employed the prospective population-based Kuopio Ischemic Heart Disease cohort study comprising of middle-aged men (42–60 years). CVH scores were computed among 2607 participants at baseline and categorized as optimum (0–4), average (5–9), or inadequate (10–14) CVH. Multivariate cox regression models were used to estimate the hazard ratios (HR) and 95% confidence intervals (CIs) of CVH score for cardiovascular mortality.

Results: During a median follow-up period of 25.8 years, 609 CVD mortality cases were recorded. The risk of CVD mortality increased gradually with increasing CVH score across the range 3–14 (p-value for non-linearity =.77). Men with optimum CVH score had HR (95% CI) for CVD mortality of 0.30 (CI 0.21 – 0.42, p?<?.0001) compared to those with inadequate CVH score after adjustment for conventional cardiovascular risk factors.

Conclusions: CVH score was strongly and continuously associated with the risk of CVD mortality among middle-aged Finnish population and this was independent of other conventional risk factors.

• Key messages

• Achieving optimum cardiovascular health score reduces the risk of cardiovascular mortality.

• Adopting the American Heart Association’s cardiovascular health metrics is a welcome approach for public health awareness and monitoring of cardiovascular health among Scandinavian population.

     

Lipoprotein(a): Current Evidence for a Physiologic Role and the Effects of Nutraceutical Strategies

PurposeCardiovascular (CV) diseases account for most worldwide mortality, and a higher level of lipoprotein (Lp)-(a) is recognized as a prevalent contributing risk factor. However, there is no consensus regarding nutritional strategies for lowering Lp(a) concentration. Thus, the purposes of this literature review were to: (1) critically examine data concerning the effects of dietetic interventions and nutraceutical agents on Lp(a) level; and (2) review the feasibility and utility of their clinical use.MethodsA literature search was conducted for studies published between August 2018 and March 2019. The search was performed using the Cochrane, Medline, and Web of Science databases. In order to expand the research, there were no delimitations on the type or year of the studies. A total of 1932 articles were identified using this search procedure. After duplicates were eliminated, 740 abstracts of articles written in English were screened to identify those of highest relevance. In the final tally, a total of 152 full-text articles were included in this review.FindingsSeveral foods and decreases in saturated fat and ethanol intake, especially red wine intake, may lower Lp(a) concentration, but limits are necessary. Coffee and tea intake may decrease Lp(a) level; further investigation is crucial before they can be considered potent Lp(a)-lowering agents. Among supplementation strategies, only l-carnitine and coenzyme Q10 are promising clinical candidates to lower Lp(a) level. Since both l-carnitine and coenzyme Q10 supplementation are commonly used for CV support, they deserve further exploration regarding clinical applicability. In contrast, despite potential CV benefits, current research fails to justify use of higher intakes of vitamin C, soy isoflavones, garlic, and ω-3 for decreasing Lp(a) concentration.ImplicationsDefinitive long-term clinical trials are needed to confirm the effects of dietetic interventions and nutraceutical agents on Lp(a) concentration when anticipating improved CV outcomes.     

Efficacy and Tolerability of Pitavastatin Versus Pitavastatin/Fenofibrate in High-risk Korean Patients with Mixed Dyslipidemia: A Multicenter,Randomized, Double-blinded,Parallel, Therapeutic Confirmatory Clinical Trial

PurposeDyslipidemia is an important risk factor for cardiovascular disease (CVD). Statins are known to effectively reduce not only low-density lipoprotein cholesterol (LDL-C) level but also death and nonfatal myocardial infarction due to coronary heart disease. The risk for CVD from atherogenic dyslipidemia persists when elevated triglyceride (TG) and reduced high-density lipoprotein cholesterol (HDL-C) levels are not controlled with statin therapy. Therefore, statin/fenofibrate combination therapy is more effective in reducing CVD risk. Here, we assessed the efficacy and tolerability of pitavastatin/fenofibrate combination therapy in patients with mixed dyslipidemia and a high risk for CVD.MethodsThis multicenter, randomized, double-blind, parallel-group, therapeutic-confirmatory clinical trial evaluated the efficacy and tolerability of fixed-dose combination therapy with pitavastatin/fenofibrate 2/160 mg in Korean patients with a high risk for CVD and a controlled LDL-C level (<100 mg/dL) and a TG level of 150–500 mg/dL after a run-in period with pitavastatin 2 mg alone. In the 8-week main study, 347 eligible patients were randomly assigned to receive pitavastatin 2 mg with or without fenofibrate 160 mg after a run-in period. In the extension study, patients with controlled LDL-C and non–HDL-C (<130 mg/dL) levels were included after the completion of the main study. All participants in the extension study received the pitavastatin/fenofibrate combination therapy for 16 weeks for the assessment of the tolerability of long-term treatment.FindingsThe difference in the mean percentage change in non–HDL-C from baseline to week 8 between the combination therapy and monotherapy groups was −12.45% (95% CI, −17.18 to −7.72), and the combination therapy was associated with a greater reduction in non-HDL-C. The changes in lipid profile, including apolipoproteins, fibrinogen, and high-sensitivity C-reactive protein from baseline to weeks 4 and 8 were statistically significant with combination therapy compared to monotherapy at all time points. Furthermore, the rates of achievement of non–HDL-C and apolipoprotein B targets at week 8 in the combination therapy and monotherapy groups were 88.30% versus 77.98% (P = 0.0110) and 78.94% versus 68.45% (P = 0.0021), respectively. The combination therapy was well tolerated, with a safety profile similar to that of statin monotherapy.ImplicationsIn these Korean patients with mixed dyslipidemia and a high risk for CVD, combination therapy with pitavastatin/fenofibrate was associated with a greater reduction in non–HDL-C compared with that with pitavastatin monotherapy, and a significantly improvement in other lipid levels. Moreover, the combination therapy was well tolerated, with a safety profile similar to that of statin monotherapy. Therefore, pitavastatin/fenofibrate combination therapy could be effective and well tolerated in patients with mixed dyslipidemia. ClinicalTrials.gov identifier: NCT03618797.     

Sea Change for Marine Omega-3s: Randomized Trials Show Fish Oil Reduces Cardiovascular Events

Recently, 3 large randomized controlled trials (RCTs) have assessed the effects of supplementation with marine omega-3 fatty acids on the occurrence of cardiovascular disease (CVD) events. We reviewed this evidence and considered it in the context of the large and growing body of data on the CV health effects of marine omega-3s. One RCT examining 8179 patients, most with coronary heart disease (CHD), reported that 4 grams/day of a highly purified omega-3 product containing eicosapentaenoic acid (EPA) reduced the risk for major adverse CV events by 25% (P<.001). Two other recent RCTs in primary prevention populations showed that approximately 1 gram/day of purified fish oil containing 840 mg/day of EPA and docosahexaenoic acid (DHA) significantly reduced risks of CHD and CV death, especially in individuals who did not consume fish and seafood frequently. The American Heart Association (AHA) continues to emphasize the importance of marine omega-3s as a nutrient for potentially reducing risks of congestive heart failure, CHD, ischemic stroke, and sudden cardiac death. Marine omega-3s should be used in high doses for patients with CHD on statins who have elevated triglycerides and at about 1 gram/day for primary prevention for individuals who do not consume at least 1.5 fish or seafood meals per week.     

Acne vulgaris

Abstract

Emphasis on diet to improve the cardiovascular (CV) risk profile has been the focus of many studies. Recently, virgin coconut oil (VCO) has been growing in popularity due to its potential CV benefits. The chemical properties and the manufacturing process of VCO make this oil healthier than its copra-derived counterpart. This review highlights the mechanism through which saturated fatty acids contribute to CV disease (CVD), how oils and fats contribute to the risk of CVD, and the existing views on VCO and how its cardioprotective effects may make this a possible dietary intervention in isolation or in combination with exercise to help reduce the burden of CVDs.     

24-h urinary sodium excretion and the risk of adverse outcomes

Abstract

Aims

The objective was to evaluate whether sodium intake, assessed with the gold standard 24-h urinary collections, was related to long-term incidence of death, cardiovascular disease (CVD) and diabetes mellitus (DM).     

Gender differences in the cardiovascular effects of sex hormones

Over the last decade, compelling evidence supports the idea that the different impact of cardiovascular disease (CVD) and the differences in vascular biology in men and women may be, at least in part, related to the cardiovascular and metabolic effects of sex steroid hormones. Indeed, androgens and oestrogens influence a multitude of vascular biological processes and their cardiovascular effects are multifaceted. While in women the effects of androgens mainly depend upon oestrogens’ levels and, ultimately, upon the estradiol/testosterone ratio, the effects of androgens in men mostly relate to their aromatization into oestrogens. Oestrogens exert potential beneficial effects on the cardiovascular system in both sexes. In women, the effect of oestrogens, alone or in association with progestins, has been widely investigated, but data obtained from older patient populations have lead the medical community and the general public to misleading conclusions. Growing evidence supports the ‘timing hypothesis’, which suggests that oestrogen/hormone replacement therapy may increase CVD risk if started late after menopause, but produce beneficial cardiovascular effects in younger postmenopausal women. Because in men adequate interventional studies with testosterone are lacking, specific investigations should be performed.     

Vitamin D status,gender and cardiovascular diseases: a systematic review of prospective epidemiological studies

Introduction: Vitamin D deficiency is highly suggested as an emerging risk factor in primary and secondary cardiovascular disease (CVD) prevention. However, there remains controversy regarding the need for vitamin D supplementation in high CVD risk individuals to prevent cardiac episodes and to achieve a better prognosis. Another literature gap is the potential existence of sex-specific associations of this factor with major CVD events or surrogate markers. The interaction of vitamin D and its metabolites with gene-mediated paths as well as lifestyle parameters sets the hypothesis for different effect of this factor on vascular health between men and women.

Areas covered: The aim of the systematic review was to summarize the hitherto data on the association of vitamin D with CVD prevention or progression, separately for men and women. Studies were eligible if they were published research epidemiological studies evaluating the gender-specific effect of vitamin D metabolic serum concentrations on CVD onset, progression or mortality.

Expert opinion: An unequivocal association between vitamin D deficiency and CVD has been demonstrated by large-scale epidemiological studies yet with inconclusive remarks from the standpoint of sex-specific highlights. Epidemiological and experimental studies designed to draw conclusions specified in men and women are demanded.     

The Obesity Paradox: Impact of Obesity on the Prevalence and Prognosis of Cardiovascular Diseases

Practice Pearl

This study summarizes the adverse effects of obesity on CV disease risk factors and its role in the genesis of HTN, HF, CHD, and the obesity paradox.     

Oestrogen replacement therapy and coronary heart disease

This review highlights recent progress in our understanding of the beneficial effects of hormone replacement therapy (HRT) in cardiovascular disease (CVD). The fact that HRT is increasingly advocated has raised concern about possible adverse effects weighed against the potential benefits of HRT regimens. Both favourable and unfavourable effects of oestrogens and HRT regimens on CVD risk factors are increasingly recognized. Consequently, the picture on cardiovascular effects of oestrogen and HRT has become more complicated, and research in this field has extended to novel areas.     

Significant interactions between traditional risk factors affect cardiovascular risk prediction in healthy general population

Abstract

Aims. The aim was to carry out a systematic screening of interactions between the traditional risk factors and to evaluate which interactions are truly relevant for estimation of cardiovascular disease (CVD) risk.

Methods. Cox regression was used in a meta-analysis of five independent, population-based health examination surveys (the National FINRISK Study). End-points were 10-year incidence of coronary heart disease (CHD), ischemic stroke (IS), and CVD in a population free of cardiovascular disease (n = 35,460).

Results. In addition to expected age interactions, systolic blood pressure was found to be a markedly stronger risk factor for CVD (and for CHD) among subjects with normal BMI (BMI < 25: HR 1.42 [1.30–1.55] for one SD increase in systolic blood pressure) when compared to obese subjects (BMI > 30: HR 1.10 [1.01–1.19]) (P < 0.001 for interaction) and among subjects with highest high-density lipoprotein (HDL) (33% tertile: HR 1.43 [1.29–1.58]) when compared to subjects with low HDL (lowest 33% tertile: HR 1.20 [1.13–1.28]) (P < 0.001 for interaction). Interactions improved risk prediction of CVD (cross-validated continuous net reclassification improvement [NRI] 49.4% with 95% CI 44.7%–54.1%, P < 0.0001 and clinical NRI 4.7%, with 95% CI 2.8%–6.5%, P < 0.0001). The C-statistic improved from 0.8438 to 0.8455 (P = 0.010). No significant interaction was associated with the risk of IS.

Conclusions. There are significant effect modifications between major risk factors, and accounting for them leads to significantly more accurate estimation of cardiovascular risk.