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1.
Normal-weight central obesity: Unique hazard of the toxic waist.
Bosomworth, NJ
Canadian family physician Medecin de famille canadien. 2019;(6):399-408
Abstract
OBJECTIVE To examine the mortality risk presented by normal-weight central obesity, to identify a clinical measure to aid in the identification of this phenotype, and to explore the means for mitigation of this risk. QUALITY OF EVIDENCE Only prospective cohort studies (level II) comparing participants with central obesity at normal weight with those at higher levels of body mass index (BMI) were found. Good level I studies were available to demonstrate the effect of diet and exercise interventions on central obesity and mortality. MAIN MESSAGE Participants with atherogenic dyslipidemia who are centrally obese at normal BMI are at similar, and possibly higher, mortality risk compared with those who are centrally obese and overweight or obese according to their BMI. Waist-to-height ratio might be the most pragmatic clinical measure of central obesity. The Mediterranean diet is an effective intervention to prevent ongoing weight gain while reducing abdominal girth. Low levels of exercise can also reduce waist circumference. Weight loss need not be an objective. CONCLUSION A waist-to-height ratio exceeding 0.5 at normal BMI identifies elevated mortality risk for cardiometabolic disease. This risk might equal or exceed that of centrally obese patients who are overweight or obese. Modest dietary and exercise interventions can be effective in mitigation of this risk.
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2.
HDL cholesterol and ASCVD risk stratification: A debate.
Barter, P, Genest, J
Atherosclerosis. 2019;:7-12
Abstract
This debate is designed to review the usefulness of the cholesterol mass within high-density lipoproteins (HDL-C) to predict the risk of atherosclerotic cardiovascular disease (ASCVD). PRO: There is much current confusion regarding the role of high density lipoproteins (HDLs) in atherosclerotic cardiovascular disease (ASCVD). While it is an established fact that the concentration of HDL cholesterol is a robust, independent, inverse predictor of the risk of having an ASCVD event, recent studies have questioned whether HDLs actually protect against ASCVD. But this in no way challenges that fact that the concentration of HDL cholesterol is a powerful tool to be used in risk stratification of ASCVD. CON: The measurement of HDL-C in the 1970 heralded a new area of promising and exciting research in cardiovascular disease. The measurement of HDL-C has been part of cardiovascular risk stratification for the past three decades. HDL have pleotropic beneficial effects on the arterial vasculature and promote the removal of excess cholesterol from lipid laden macrophages. These effects are only weakly correlated with HDL-C levels. While HDL-C is associated with atherosclerotic cardiovascular disease, the epidemiological relationship falters at the extremes of measurement. Mendelian randomization does not support a link of causality and to date, attempts to raise HDL-C pharmacologically have not yielded the expected outcomes. The time has come to consider abandoning HDL-C for cardiovascular risk prediction and clinical decision making and to double efforts to develop better biomarkers of HDL function.
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3.
Stroke Risk in Atrial Fibrillation: Beyond the CHA2DS2-VASc Score.
Jagadish, PS, Kabra, R
Current cardiology reports. 2019;(9):95
Abstract
PURPOSE OF REVIEW Stroke prevention is the cornerstone of atrial fibrillation (AF) management and the anticoagulation decision is currently based on CHA2DS2-VASc risk score. We discuss several novel risk factors besides those included in CHA2DS2-VASc score and alternative models for stroke prediction. RECENT FINDINGS Several clinical markers including obstructive sleep apnea and renal failure, laboratory markers like brain natriuretic peptide, imaging criteria including left atrial appendage morphology, spontaneous echo contrast, and coronary artery calcium score may predict stroke in AF patients. Addition of African American ethnicity to CHA2DS2-VASc score also improves stroke prediction in AF. Finally, novel models including TIMI-AF score, ATRIA score, and GARFIELD-AF scores have potential roles in risk stratification for stroke. While CHA2DS2-VASc score is the currently recommended risk stratification model for stroke prediction in AF, use of additional clinical, laboratory, imaging markers, ethnicity, and novel stroke prediction models may further assist in decision to anticoagulate the AF patient for stroke prevention.
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4.
Atrial high-rate episodes: prevalence, stroke risk, implications for management, and clinical gaps in evidence.
Bertaglia, E, Blank, B, Blomström-Lundqvist, C, Brandes, A, Cabanelas, N, Dan, GA, Dichtl, W, Goette, A, de Groot, JR, Lubinski, A, et al
Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2019;(10):1459-1467
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Abstract
Self-terminating atrial arrhythmias are commonly detected on continuous rhythm monitoring, e.g. by pacemakers or defibrillators. It is unclear whether the presence of these arrhythmias has therapeutic consequences. We sought to summarize evidence on the prevalence of atrial high-rate episodes (AHREs) and their impact on risk of stroke. We performed a comprehensive, tabulated review of published literature on the prevalence of AHRE. In patients with AHRE, but without atrial fibrillation (AF), we reviewed the stroke risk and the potential risk/benefit of oral anticoagulation. Atrial high-rate episodes are found in 10-30% of AF-free patients. Presence of AHRE slightly increases stroke risk (0.8% to 1%/year) compared with patients without AHRE. Atrial high-rate episode of longer duration (e.g. those >24 h) could be associated with a higher stroke risk. Oral anticoagulation has the potential to reduce stroke risk in patients with AHRE but is associated with a rate of major bleeding of 2%/year. Oral anticoagulation is not effective in patients with heart failure or survivors of a stroke without AF. It remains unclear whether anticoagulation is effective and safe in patients with AHRE. Atrial high-rate episodes are common and confer a slight increase in stroke risk. There is true equipoise on the best way to reduce stroke risk in patients with AHRE. Two ongoing trials (NOAH-AFNET 6 and ARTESiA) will provide much-needed information on the effectiveness and safety of oral anticoagulation using non-vitamin K antagonist oral anticoagulants in patients with AHRE.
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5.
The challenge of asymptomatic coronary artery disease in aircrew; detecting plaque before the accident.
Gray, G, Davenport, ED, Bron, D, Rienks, R, d'Arcy, J, Guettler, N, Manen, O, Syburra, T, Nicol, ED
Heart (British Cardiac Society). 2019;(Suppl 1):s17-s24
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Abstract
Coronary events remain a major cause of sudden incapacitation, including death, in both the general population and among aviation personnel, and are an ongoing threat to flight safety and operations. The presentation is often unheralded, especially in younger adults, and is often due to rupture of a previously non-obstructive coronary atheromatous plaque. The challenge for aeromedical practitioners is to identify individuals at increased risk for such events. This paper presents the NATO Cardiology Working Group (HFM 251) consensus approach for screening and investigation of aircrew for asymptomatic coronary disease.A three-phased approach to coronary artery disease (CAD) risk assessment is recommended, beginning with initial risk-stratification using a population-appropriate risk calculator and resting ECG. For aircrew identified as being at increased risk, enhanced screening is recommended by means of Coronary Artery Calcium Score alone or combined with a CT coronary angiography investigation. Additional screening may include exercise testing, and vascular ultrasound imaging. Aircrew identified as being at high risk based on enhanced screening require secondary investigations, which may include functional ischaemia, and potentially invasive coronary angiography. Functional stress testing as a stand-alone investigation for significant CAD is not recommended in aircrew. Aircrew identified with coronary disease require further clinical and aeromedical evaluation before being reconsidered for flying status.
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6.
Opportunities for improving use of evidence-based therapy in patients with type 2 diabetes and cardiovascular disease.
Gao, Y, Peterson, E, Pagidipati, N
Clinical cardiology. 2019;(11):1063-1070
Abstract
Evidence-based therapy that target hyperlipidemia, hypertension, smoking cessation, and weight loss have demonstrated significant benefits in reducing cardiovascular risks and related events. Although the benefit of intensively lowering blood glucose is unclear, newer antidiabetic drugs (glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors) have shown cardiovascular benefits in addition to their antihyperglycemic effect. Yet, studies suggest that recent use of evidence-based therapy and management of cardiovascular risk among individuals with type 2 diabetes (T2D) and cardiovascular disease (CVD) remains largely suboptimal. The following narrative review first identifies barriers to translating research evidence to clinical practice at the levels of provider, health system, patient, and cost. Then it synthesizes previous implementation strategies that addressed multifaceted barriers and attempted to improve care for patients with T2D and CVD. In conclusion, team-based care coordination, reminding systems in combination to pharmacist consultation and patient education, provider education compatible with clinical workflow, and coupled incentives between providers and patients appeared to be effective in reducing cardiovascular risks for patients with T2D and CVD, though the scalability and long-term clinical effect of these strategies as well as the possibility of interventions involving payers and health systems remain uncertain.
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7.
Risk Factor Variability and Cardiovascular Outcome: JACC Review Topic of the Week.
Messerli, FH, Hofstetter, L, Rimoldi, SF, Rexhaj, E, Bangalore, S
Journal of the American College of Cardiology. 2019;(20):2596-2603
Abstract
Until recently, intraindividual visit-to-visit variability of cardiovascular risk factors has been dismissed as random fluctuation. This simplistic concept was challenged by demonstrating that visit-to-visit blood pressure variability, independent of average blood pressure, was a powerful risk factor for stroke. Subsequently, variability of other cardiovascular risk factors such as cholesterol, glycemia, and body weight was documented to increase risk independent of their absolute values. Variability of these risk factors has been demonstrated to be a powerful predictor for all-cause and cardiovascular mortality, stroke, coronary artery disease, heart failure, end-stage renal disease, and dementia. With the notable exception of heart rate, cardiovascular risk factors must now be defined by 2 components: the magnitude and duration of sustained risk factor elevation and, equally important, the variability of the same risk factor over time.
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Human health risk associated with the management of phosphorus in freshwaters using lanthanum and aluminium.
D'Haese, PC, Douglas, G, Verhulst, A, Neven, E, Behets, GJ, Vervaet, BA, Finsterle, K, Lürling, M, Spears, B
Chemosphere. 2019;:286-299
Abstract
The use of geo-engineering materials to manage phosphorus in lakes has increased in recent years with aluminium and lanthanum based materials being most commonly applied. Hence the potential impact of the use of these compounds on human health is receiving growing interest. This review seeks to understand, evaluate and compare potential unintended consequences on human health and ecotoxicological risks associated with the use of lanthanum- and aluminium-based materials to modify chemical and ecological conditions in water bodies. In addition to their therapeutic use for the reduction of intestinal phosphate absorption in patients with impaired renal function, the phosphate binding capacity of aluminium and lanthanum also led to the development of materials used for water treatment. Although lanthanum and aluminium share physicochemical similarities and have many common applications, their uptake and kinetics within the human body and living organisms importantly differ from each other which is reflected in a different toxicity profile. Whilst a causal role in the development of neurological pathologies, skeletal lesions, hematopoietic disorders and respiratory effects has unequivocally been demonstrated with increased exposure to aluminium, studies until now have failed to find such a clear association after exposure to lanthanum although caution is warranted. Our review indicates that lanthanum and aluminium have a distinctly different profile with respect to their potential effects on human health. Regular monitoring of both aluminium and lanthanum concentrations in lanthanum-/aluminium-treated water by the responsible authorities is recommended to avoid acute accidental or chronic low level accumulation.
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Assessment and significance of sarcopenia in liver transplantation.
Nam, NH, Kaido, T, Uemoto, S
Clinical transplantation. 2019;(12)
Abstract
Sarcopenia frequently occurs in cirrhotic patients who are waiting for liver transplantation (LT). This disease is associated with increased morbidity and mortality rates during the LT period. Recently, the careful assessment of nutritional status for end-stage liver disease patients has received a great deal of attention; hence, numerous methods of evaluating sarcopenia have been proposed. However, most of the methods have limitations, including a lack of objectivity, reproducibility, and ability to discriminate prognoses. In addition, many reports suggest that sarcopenia be used as an adjustment factor for the selection criteria of LT and that sarcopenia be incorporated into the selection criteria for living donor LT in our center. In this article, based on a literature review, we aim to identify the current definition of sarcopenia, the available methods of measurement, the potential novel interventions for the treatment of malnutrition and the significance of sarcopenia in LT.
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10.
The Role of Troponin for Acute Heart Failure.
Harrison, N, Favot, M, Levy, P
Current heart failure reports. 2019;(1):21-31
Abstract
PURPOSE OF REVIEW To review the mechanisms, clinical interpretation, prognostic role, and future research regarding cardiac troponin (cTn) in the assessment of acute heart failure (AHF) patients presenting to the emergency department (ED). RECENT FINDINGS cTn has become a necessary component of the evaluation of AHF patients in the ED, largely because of its independently predictive value as a prognosticator of poor outcome. High-sensitivity assays (hs-cTn) may add risk stratification value beyond conventional assays, specifically with regard to identifying low-risk AHF patients. Moreover, as the complex mechanisms of cTn release in AHF continue to be elucidated, recent studies suggest that many of the key hemodynamic derangements that define specific AHF syndromes may also be direct culprits in cTn release. cTn is released in AHF in response to both non-ischemic (e.g., increased afterload, increased preload, inflammatory signaling, altered calcium handling) and ischemic mechanisms. cTn detectable on conventional sensitivity assays predicts poor prognosis when measured in the ED or when noted in historical data such as past ED visits or at the time of discharge from the most recent AHF hospitalization. hs-cTn assays provide detectable values in nearly all AHF patients. Evidence is evolving on using hs-cTn levels below the upper limit of normal to potentially identify low-risk ED patients, and further research is needed. Among the classically cited risk factors for AHF mortality, cTn and natriuretic peptides stand as independent and synergistic prognostic factors even after adjustment for confounders. Many other risk factors, such as ejection fraction, often failed to retain ED prognostic value beyond these two biomarkers.