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1.
Reexamination of the Embolic Stroke of Undetermined Source Concept.
Albers, GW, Bernstein, R, Brachmann, J, Camm, AJ, Fromm, P, Goto, S, Granger, CB, Hohnloser, SH, Hylek, E, Krieger, D, et al
Stroke. 2021;(8):2715-2722
Abstract
Occult atrial fibrillation (AF) is a leading cause of stroke of unclear cause. The optimal approach to secondary stroke prevention for these patients remains elusive. The term embolic stroke of undetermined source (ESUS) was coined to describe ischemic strokes in which the radiographic features demonstrate territorial infarcts resembling those seen in patients with confirmed sources of embolism but without a clear source of embolism detected. It was assumed that patients with ESUS had a high rate of occult AF and would benefit from treatment with direct oral anticoagulants, which are at least as effective as vitamin K antagonists for secondary stroke prevention in patients with AF, but with a much lower risk of intracerebral hemorrhage. Two recent large randomized trials failed to show superiority of direct oral anticoagulants over aspirin in ESUS patients. These findings prompt a reexamination of the ESUS concept, with the goal of improving specificity for detecting patients with a cardioembolic cause. Based on the negative trial results, there is renewed interest in the role of long-term cardiac monitoring for AF in patients who fit the current ESUS definition, as well as the clinical implication of detecting AF. Ongoing trials are exploring these questions. Current ESUS definitions do not accurately detect the patients who should be prescribed direct oral anticoagulants, potentially because occult AF is less common than expected in these patients and/or anticoagulants may be less beneficial in patients with ESUS but no AF than they are for patients with stroke with established AF. More specific criteria to identify patients who may be at higher risk for occult AF and reduce their risk of subsequent stroke have been developed and are being tested in ongoing clinical trials.
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2.
New Avenues for Optimal Treatment of Atrial Fibrillation and Stroke Prevention.
De Marchis, GM, Sposato, LA, Kühne, M, Dittrich, TD, Bonati, LH, Fischer, U, Chaturvedi, S
Stroke. 2021;(4):1490-1499
Abstract
One in 3 individuals free of atrial fibrillation (AF) at index age 55 years is estimated to develop AF later in life. AF increases not only the risk of ischemic stroke but also of dementia, even in stroke-free patients. In this review, we address recent advances in the heart-brain interaction with focus on AF. Issues discussed are (1) the timing of direct oral anticoagulants start following an ischemic stroke; (2) the comparison of direct oral anticoagulants versus vitamin K antagonists in early secondary stroke prevention; (3) harms of bridging with heparin before direct oral anticoagulants; (4) importance of appropriate direct oral anticoagulants dosing; (5) screening for AF in high-risk populations, including the role of wearables; (6) left atrial appendage occlusion as an alternative to oral anticoagulation; (7) the role of early rhythm-control therapy; (8) effect of lifestyle interventions on AF; (9) AF as a risk factor for dementia. An interdisciplinary approach seems appropriate to address the complex challenges posed by AF.
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3.
Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) guidelines for management of dyslipidemia and cardiovascular disease risk reduction: Putting evidence in context.
Al Rifai, M, Blumenthal, RS, Stone, NJ, Schofield, RS, Orringer, CE, Michos, ED, Heidenreich, PA, Braun, L, Birtcher, KK, Smith, SC, et al
Progress in cardiovascular diseases. 2021;:2-6
Abstract
Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality in the United States (U.S.) and incurs significant cost to the healthcare system. Management of cholesterol remains central for ASCVD prevention and has been the focus of multiple national guidelines. In this review, we compare the American Heart Association (AHA)/American College of Cardiology (ACC) and the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) Cholesterol guidelines. We review the evidence base that was used to generate recommendations focusing on 4 distinct themes: 1) the threshold of absolute 10-year ASCVD risk to start a clinician-patient discussion for the initiation of statin therapy in primary prevention patients; 2) the utility of coronary artery calcium score to guide clinician-patient risk discussion pertaining to the initiation of statin therapy for primary ASCVD prevention; 3) the use of moderate versus high-intensity statin therapy in patients with established ASCVD; and 4) the utility of ordering lipid panels after initiation or intensification of lipid lowering therapy to document efficacy and monitor adherence to lipid lowering therapy. We discuss why the VA/DoD and AHA/ACC may have reached different conclusions on these key issues.
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4.
New Approaches for the Prevention and Treatment of Cardiovascular Disease: Focus on Lipoproteins and Inflammation.
Hussain, A, Ballantyne, CM
Annual review of medicine. 2021;:431-446
Abstract
Although numerous trials have convincingly shown benefits of statin therapy in both primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD), most showed relative risk reductions of 25-40%, and thus many individuals continue to have ASCVD events despite statin therapy. Substantial progress has been made in developing therapies that address the residual risk for ASCVD despite statin therapy. In this review, we summarize progress of currently available therapies along with therapies under development that further reduce low-density lipoprotein cholesterol and apolipoprotein B-containing lipoproteins, reduce lipoprotein(a), reduce ASCVD events in patients with high triglycerides, and directly target inflammation to reduce ASCVD risk.
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5.
Closing Gaps in Lifestyle Adherence for Secondary Prevention of Coronary Heart Disease.
Aggarwal, M, Ornish, D, Josephson, R, Brown, TM, Ostfeld, RJ, Gordon, N, Madan, S, Allen, K, Khetan, A, Mahmoud, A, et al
The American journal of cardiology. 2021;:1-11
Abstract
The secondary prevention (SP) of coronary heart disease (CHD) has become a major public health and economic burden worldwide. In the United States, the prevalence of CHD has risen to 18 million, the incidence of recurrent myocardial infarctions (MI) remains high, and related healthcare costs are projected to double by 2035. In the last decade, practice guidelines and performance measures for the SP of CHD have increasingly emphasized evidence-based lifestyle (LS) interventions, including healthy dietary patterns, regular exercise, smoking cessation, weight management, depression screening, and enrollment in cardiac rehabilitation. However, data show large gaps in adherence to healthy LS behaviors and low rates of enrollment in cardiac rehabilitation in patients with established CHD. These gaps may be related, since behavior change interventions have not been well integrated into traditional ambulatory care models in the United States. The chronic care model, an evidence-based practice framework that incorporates clinical decision support, self-management support, team-care delivery and other strategies for delivering chronic care is well suited for both chronic CHD management and prevention interventions, including those related to behavior change. This article reviews the evidence base for LS interventions for the SP of CHD, discusses current gaps in adherence, and presents strategies for closing these gaps via evidence-based and emerging interventions that are conceptually aligned with the elements of the chronic care model.
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6.
The role of diet in secondary stroke prevention.
English, C, MacDonald-Wicks, L, Patterson, A, Attia, J, Hankey, GJ
The Lancet. Neurology. 2021;(2):150-160
Abstract
Poor quality diet and nutrition is strongly associated with risk of first stroke, and adherence to a Mediterranean-style diet has been reported to reduce the risk of first stroke. The association between diet quality and the risk of recurrent stroke is less certain and there is no reliable evidence that improving diet quality or dietary supplementation reduces recurrent stroke risk. Current evidence is largely based on epidemiological studies of diverse dietary approaches, ranging from nutritional supplements to specific foods, food groups, and dietary patterns, and is difficult to interpret. In the absence of reliable evidence from randomised clinical trials, the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach can be used to assess the potential causal role of diet quality and interventions in reducing recurrent stroke, and to provide guidance for clinical practice and directions for future research. Further work is needed to identify and develop the most promising dietary interventions for evaluation by large randomised clinical trials.
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7.
Mediterranean-Style Diet for the Primary and Secondary Prevention of Cardiovascular Disease: A Cochrane Review.
Rees, K, Takeda, A, Martin, N, Ellis, L, Wijesekara, D, Vepa, A, Das, A, Hartley, L, Stranges, S
Global heart. 2020;(1):56
Abstract
BACKGROUND Diet plays a major role in cardiovascular disease (CVD) risk. OBJECTIVES To determine the effectiveness of a Mediterranean-style diet for the primary and secondary prevention of CVD. METHODS We searched for randomised controlled trials (RCTs) of Mediterranean-style diets in healthy adults and those at increased risk of CVD (primary prevention) and with established CVD (secondary prevention). RESULTS Thirty RCTs were included, 22 in primary prevention and eight in secondary prevention. Clinical endpoints were reported in two trials where there was moderate quality evidence for a reduction in strokes for primary prevention, and low quality evidence for a reduction in total and CVD mortality in secondary prevention. We found moderate quality evidence of improvement in CVD risk factors for primary prevention and low quality evidence of little or no effect in secondary prevention. CONCLUSIONS There is still some uncertainty regarding the effects of a Mediterranean-style diet in CVD prevention.
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8.
RISK-FACTORS OF CORONARY ARTERY DISEASE (REVIEW).
Kantaria, M, Buleishvili, M, Kipiani, NV, Ormotsadze, G, Sanikidze, T
Georgian medical news. 2020;(299):78-82
Abstract
The treatment of coronary arteries disease (CAD) and the prevention of their complications, intervention on the coronary arteries is usually recommended. In this review, with the aim of improving the treatment outcomes of patients with CAD, requiring percutaneous coronary intervention and/or coronary artery bypass grafting,risk factors of developing coronary syndrome are discussed. Understanding the causes of the disturbance of coronary artery conduction will provide a new perspective for improving patient treatment outcomes. Revascularization cannot protect against future acute thrombotic events; for the successful treatment of CAD combining optimal revascularization strategies with long-term measures of risk reduction in lifestyle, often in combination with pharmacological measures, is needed. Numerous primary and secondary prevention trials have shown that management of modifiable risk factors (reduction in LDL-cholesterol level, decrease in blood pressure, discontinuation of smoking) reduces death rates, myocardial infarction, stroke, and other cardiovascular events, including the need for revascularization. Refined guidelines for the primary and secondary prevention of atherosclerosis account for modifiable and nonmodifiable, and other emerging risk factors of CAD.
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9.
Prevention of recurrent urinary stone disease.
Goka, SQ, Copelovitch, L
Current opinion in pediatrics. 2020;(2):295-299
Abstract
PURPOSE OF REVIEW Urinary stone disease (USD) is increasing in prevalence and recurrence is common. In pediatrics, most stones are composed primarily of calcium with the highest incidence observed in adolescents. Given the morbidity associated with USD, an in depth review of current management strategies is of paramount importance to highlight the data supporting the recommended treatments and the knowledge gaps which still exist. RECENT FINDINGS Several interventions for the management of recurrent calcium USD in children have been recommended based on primarily adult studies. These interventions include modification of diet and fluid intake in addition to the utilization of medications such as thiazide diuretics and citrates when supportive care is inadequate. Overall there is conflicting data in the adult literature which is further complicated by our attempts to extrapolate these data to children. SUMMARY Based on the currently available literature the management of USD in pediatrics should be individualized to each patient and focused on the particular metabolic risk factors that are identified during the course of their evaluation. Several interventions may be required or trialed in a particular patient to show an effect. Well designed trials to assess the efficacy of each intervention in the pediatric population are needed.
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10.
Primary versus secondary cardiorenal prevention in type 2 diabetes: Which newer anti-hyperglycaemic drug matters?
Giugliano, D, Ceriello, A, De Nicola, L, Perrone-Filardi, P, Cosentino, F, Esposito, K
Diabetes, obesity & metabolism. 2020;(2):149-157
Abstract
We are observing a resurgence of major diabetic vascular complications after a period of dramatic decrease during the period 1990 to 2010. The classical division of cardiovascular prevention into primary (with an event) and secondary (without an event) is largely used to describe cardiovascular risk in type 2 diabetes (T2D); however, there is evidence that the cardiovascular risk in diabetes may range from highest in patients who experienced a previous cardiovascular event to mild in patients with the main risk factors at target. Herein, we present details of the 14 cardiovascular outcome trials (CVOTs) published to date, including the total population investigated, and their separation into primary (T2D + multiple risk factors) and secondary prevention (T2D + established cardiovascular disease [CVD]) populations as detailed within the trials. We also summarize evidence for the effects of dipeptidyl peptidase-4 inhibitors (DPP-4i), glucagon-like peptide-1 receptor agonists (GLP1-RA) and sodium glucose co-transporter-2 inhibitors (SGLT-2i) versus placebo on the risk of major cardiovascular events (MACE), heart failure (HF) and diabetic kidney disease (DKD). In primary prevention, SGLT-2i reduce both the risk of hospitalization for HF and progression of DKD; in secondary prevention, SGLT-2i are effective on the three endpoints, DPP-4i are neutral, while GLP1-RA show mixed results.