Does Treating Subclinical Hypothyroidism Improve Markers of Cardiovascular Risk?

Subclinical hypothyroidism is defined as an elevated serum thyroid-stimulating hormone (TSH) level in the face of normal free thyroid hormone values. The overall prevalence of subclinical hypothyroidism is 4-10% in the general population and up to 20% in women aged >60 years. The potential benefits and risks of therapy for subclinical hypothyroidism have been debated for 2 decades, and a consensus is still lacking. Besides avoiding the progression to overt hypothyroidism, the decision to treat patients with subclinical hypothyroidism relies mainly on the risk of metabolic and cardiovascular alterations. Subclinical hypothyroidism causes changes in cardiovascular function similar to, but less marked than, those occurring in patients with overt hypothyroidism. Diastolic dysfunction both at rest and upon effort is the most consistent cardiac abnormality in patients with subclinical hypothyroidism, and also in those with slightly elevated TSH levels (>6 mIU/L). Moreover, mild thyroid failure may increase diastolic blood pressure as a result of increased systemic vascular resistance. Restoration of euthyroidism by levothyroxine replacement is generally able to improve all these abnormalities. Early clinical and autopsy studies had suggested an association between subclinical hypothyroidism and coronary heart disease, which has been subsequently confirmed by some, but not all, large cross-sectional and prospective studies. Altered coagulation parameters, elevated lipoprotein (a) levels, and low-grade chronic inflammation are regarded to coalesce with the hypercholesterolemia of untreated patients with subclinical hypothyroidism to enhance the ischemic cardiovascular risk. Although a consensus is still lacking, the strongest evidence for a beneficial effect of levothyroxine replacement on markers of cardiovascular risk is the substantial demonstration that restoration of euthyroidism can lower both total and low-density lipoprotein-cholesterol levels in most patients with subclinical hypothyroidism. However, the actual effectiveness of thyroid hormone substitution in reducing the risk of cardiovascular events remains to be elucidated. In conclusion, the multiplicity and the possible reversibility of subclinical hypothyroidism-associated cardiovascular abnormalities suggest that the decision to treat a patient should depend on the presence of risk factors, rather than on a TSH threshold. On the other hand, levothyroxine replacement therapy can always be discontinued if there is no apparent benefit. Levothyroxine replacement therapy is usually safe providing that excessive administration is avoided by monitoring serum TSH levels. However, the possibility that restoring euthyroidism may be harmful in the oldest of the elderly population of hypothyroid patients has been recently raised, and should be taken into account in making the decision to treat patients with subclinical hypothyroidism who are aged >85 years.     

The Risk of Cardiovascular Events on Cannabis’ Highest Day

Knowledge of the acute cardiovascular effects of cannabis consumption remains largely unknown and is important given the changing landscape of legalization of recreational cannabis use. “4/20” is an annual event where many individuals gather to consume cannabis. An increased risk of adverse health events such as motor vehicle accidents has previously been reported to occur on “4/20.” In this study, population-based administrative databases in Ontario, Canada, were used to evaluate the association between “4/20” and cardiovascular events. An increased risk of cardiovascular events on a population level was not observed on “4/20.” Additional research into the changes in the prevalence of the use of cannabis with recreational legalization and acute and chronic risk with cannabis use is suggested.     

Does Blood Pressure Variability Modulate Cardiovascular Risk?

Exactly how hypertension causes end organ damage and vascular events is poorly understood. Yet the concept that underlying “usual” blood pressure (BP) accounts for all BP-related risk of vascular events and for the benefits of BP-lowering drugs has come to underpin clinical guidelines on the diagnosis and treatment of hypertension. This article reviews evidence that variability in BP also predicts risk of stroke and other vascular events independently of mean BP and evidence that drug-class effects on variability in BP explain differences in the effectiveness of BP-lowering drugs in preventing stroke.     

Thiazolidinediones and Cardiovascular Risk — A Question of Balance

Background:

Several recent meta-analyses of adverse event data from randomized controlled trials with rosiglitazone reveal a possible association between this thiazolidinedione and an increased risk of ischemic myocardial events. This has led to debate on the overall clinical benefit of glitazone therapy for type 2 diabetes. Pioglitazone, on the other hand, has the most extensive cardiovascular outcomes database of all current glucose-lowering therapies, including a large prospective randomized controlled trial designed specifically to assess cardiovascular outcomes (PROactive). The available data suggest that pioglitazone is associated with a reduction in macrovascular risk.

Aims:

In this review, we highlight some of the key factors that need to be considered when assessing the net clinical benefit of thiazolidinediones, focussing on both class effects and those specific to either rosiglitazone or pioglitazone.

Results:

For pioglitazone there appears to be no increase in the risk of overall macrovascular events and no adverse clinical consequences of developing signs of heart failure. Furthermore, there is good evidence of significant benefit regarding the composite of death, MI or stroke.

Conclusion:

The benefits seen with pioglitazone appear to outweigh the risks.     

Does Sugar-Sweetened Beverage Consumption Influence Cardiovascular Risk Independent of Weight Gain and Obesity? an Update of the Epidemiologic Evidence

Sugar-sweetened beverages (SSBs) contain high amounts of nutrient-deficient calories in the form of rapidly digestible carbohydrates. Substantial evidence links SSB consumption to an increased risk for obesity and weight gain, which is hypothesized to result from incomplete compensatory reductions in energy intake at subsequent meals after beverage consumption. Higher levels of SSB consumption have also been associated with unfavorable levels of several other traditional cardiovascular risk factors, such as impaired glucose metabolism, hypertension, dyslipidemia, as well as a higher incidence of coronary heart disease. Although the excess obesity that results from SSB consumption likely contributes elevated risk for the development of a variety of adverse health conditions, epidemiologic evidence is emerging indicating that the relationship between SSB consumption and the incidence of cardiovascular disease events and several traditional cardiovascular risk factors is not fully explained by conventional mediators, including obesity. This review summarizes the current epidemiologic evidence from population-based and epidemiologic cohort studies that both supports and refutes the adverse impact of SSB consumption on cardiovascular health that may occur independently of obesity and weight gain.     

Adherence to Cardiovascular Disease Medications: Does Patient-Provider Race/Ethnicity and Language Concordance Matter?

Background  

Patient–physician race/ethnicity and language concordance may improve medication adherence and reduce disparities in cardiovascular disease (CVD) by fostering trust and improved patient–physician communication.     

Clinical Cardiovascular Adverse Events Reported Post-COVID-19 Vaccination: Are They a Real Risk?

Given the urgent need to control the spread of the novel COVID-19 virus, 13 vaccines have been approved for emergency use before completing all 3 phases of the clinical trials. Thereby a careful monitor of the adverse effects postvaccination is essential. We searched through PubMed and other reporting systems like VAERS for the reported cardiovascular adverse events post-COVID-19 vaccination. Through our review, we determined that the incidence of all the reported cardiovascular events is very rare. Additionally, the vaccine was initially given to the elderly and high-risk populations in which cardiovascular events such as myocardial infarction and arrhythmias are already more prevalent, while other cardiovascular events such as myocarditis or vaccine-induced thrombotic thrombocytopenia were more common in younger populations. Moreover, a direct causal relationship, if any, between vaccination and adverse events is yet to be fully elucidated. Thus, at this time point, the benefits of vaccination far outweigh the risk.     

Diet Drink Consumption and the Risk of Cardiovascular Events: A Report from the Women’s Health Initiative

BACKGROUNDData are limited regarding the influence of diet drink consumption on cardiovascular disease (CVD) outcomes.OBJECTIVEWe aimed to evaluate the relationship between diet drink intake and cardiovascular events.DESIGNWe conducted a retrospective cohort study, utilizing data from the national, multicenter Women’s Health Initiative Observational Study (WHI OS), recruiting subjects from 1993 to 1998.PATIENTSPost-menopausal women with available diet drink intake data, without pre-existing CVD and who survived ≥ 60 days were included in the study.CONCLUSIONSThis analysis demonstrates an association between high diet drink intake and CVD outcomes and mortality in post-menopausal women in the WHI OS.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-3098-0) contains supplementary material, which is available to authorized users.KEY WORDS: diet, cardiovascular diseases, lifestyle, diet drinks, artificial sweeteners     

Patterns of Cardiac Troponin I Concentrations as Risk Predictors of Cardiovascular Disease and Death: The Trøndelag Health Study

BackgroundConcentrations of cardiac troponin predict risk of cardiovascular disease and death in the general population. There is limited evidence on changing patterns of cardiac troponin in the years preceding cardiovascular events.MethodsWe analyzed cardiac troponin I (cTnI) with a high-sensitivity assay in 3272 participants in the Trøndelag Health (HUNT) Study at study visit 4 (2017-2019). Of these, 3198 had measurement of cTnI at study visit 2 (1995-1997), 2661 at study visit 3, and 2587 at all 3 study visits. We assessed the trajectories of cTnI concentrations in the years prior to cardiovascular events using a generalized linear mixed model, with adjustment for age, sex, cardiovascular risk factors, and comorbidities.ResultsAt HUNT4 baseline, median age was 64.8 (range 39.4-101.3) years, and 55% were women. Study participants who were admitted because of heart failure or died from cardiovascular cause on follow-up had a steeper increase in cTnI compared with study participants with no events (P < .001). The average yearly change in cTnI was 0.235 (95% confidence interval, 0.192-0.289) ng/L for study participants with heart failure or cardiovascular death, and −0.022 (95% confidence interval, −0.022 to −0.023) ng/L for study participants with no events. Study participants who experienced myocardial infarction, ischemic stroke, or noncardiovascular mortality exhibited similar cTnI patterns.ConclusionsFatal and nonfatal cardiovascular events are preceded by slowly increasing concentrations of cardiac troponin, independently of established cardiovascular risk factors. Our results support the use of cTnI measurements to identify at-risk subjects who progress to subclinical and later overt cardiovascular disease.     

Quality of Life in Patients With Signs and Symptoms of Heart Failure—Does Systolic Function Matter?

BackgroundThe impaired quality of life in patients with systolic heart failure is well described. Less is known about patients with preserved systolic function (PSF) heart failure.Methods and ResultsWe aimed to compare the quality of life in patients with PSF heart failure with that of those with left ventricular systolic dysfunction (LVSD) using generic and disease-specific quality-of-life questionnaires. Four hundred patients with signs and symptoms of heart failure referred for an echocardiogram to assess left ventricular function were invited to complete quality-of-life questionnaires. A total of 278 of 400 (69.5%) responses were adequate for analysis. The mean age of respondents was 72.5 (10) years; 132(47%) were male. A total of 189 of 278 (68%) had PSF, and 89 of 278 (32%) had left ventricular systolic dysfunction (LVSD). Both groups were well matched for age, but there were more women in the PSF group (58% vs. 40%). No significant differences were found in the quality of life between PSF and LVSD patients. Women had significantly worse quality of life compared with men in both groups.ConclusionPatients with PSF are an important subgroup of heart failure patients whose quality of life is as impaired as those with systolic dysfunction. These data suggest these patients warrant more care, perhaps in specialist clinics.