Appropriate Use Criteria for Echocardiography: Evolving Applications in the Era of Value-Based Healthcare

The current climate in healthcare is increasingly emphasizing a value-based approach to diagnostic testing. Cardiac imaging, including echocardiography, has been a primary target of ongoing reforms in healthcare delivery and reimbursement. The Appropriate Use Criteria (AUC) for echocardiography is a physician-derived tool intended to guide utilization in optimal patient care. To date, the AUC have primarily been employed solely as justification for reimbursement, though evolving broader applications to guide clinical decision-making suggest a far more valuable role in the delivery of high-quality and high-value healthcare.     

Role of Dual Antiplatelet Therapy in Symptomatic Patients with Established Vascular Disease: Putting the CHARISMA Trial into Therapeutic Perspective

Introduction  

The CHARISMA (Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance) trial has spurred debate over subgroup analysis interpretation and prompted renewed consideration of the long-term role of dual aspirin and clopidogrel therapy (DAPT) in patients with established vascular disease.     

Approach to Lipid Therapy in the Patient With Atherosclerotic Vascular Disease

Hyperlipidemia increases the incidence of atherosclerotic vascular disease and is associated with greater rates of recurrent cardiovascular events among individuals with established vascular disease. Several large population studies have confirmed the link between all cholesterol components (including elevated low-density lipoprotein [LDL] cholesterol, total cholesterol, and triglyceride levels, and reduced high-density lipoprotein [HDL] levels) with coronary heart disease and other manifestations of systemic atherosclerosis. In addition, landmark clinical trials have clearly established that lowering LDL cholesterol levels with statins (HMG-CoA reductase inhibitors) can lower recurrent cardiovascular events by nearly 25%. The benefits of altering non-LDL cholesterol levels (eg, triglycerides and HDL) are less clear, but several other medications are often used in conjunction with statins for cholesterol lowering. First-line therapy for lipid lowering in patients with atherosclerotic vascular disease includes statins and a recommendation for lifestyle changes (including diet and exercise). Second-line options for lowering cholesterol include fibrates, nicotinic acid, bile acid sequestrants, and ezetimibe. Therapeutic goals for patients with vascular disease are to achieve an LDL cholesterol level < 100 mg/dL, or <70 mg/dL in individuals at particularly high risk.     

Mendelian Randomization for the Identification of Causal Pathways in Atherosclerotic Vascular Disease

Epidemiological and clinical studies have identified many physiological traits and biomarkers that are statistically associated with coronary artery disease (CAD). For some of these traits and biomarkers it is well established that they represent true causal risk factors for CAD. For other biomarkers, however, the distinct character of association is still a matter of debate. Randomized controlled trials (RCT) had a pivotal role in establishing causal associations between risk factors and biomarkers and CAD in some settings by demonstrating that therapeutic intervention targeting risk factors/biomarkers also affect the risk for clinical outcomes, such as CAD. In other scenarios, however, RCTs did not demonstrate clear benefits associated with lowering biomarker levels and therefore suggest that the association between these biomarkers (like C reactive protein) and CAD was driven by confounding or reverse causation. Even accurately conducted RCTs are not immune against incorrect causal inference. Moreover, the extensive costs and efforts required to conduct RCTs asked for alternative study designs to elucidate potential causal associations. Mendelian Randomization studies represent one such alternative by using genetic variants as proxies for specific biomarkers to investigate potential causal relations between biomarkers and clinical outcomes. In this review, we briefly describe the principles of MR studies and summarize recent MR studies in the context of CAD.     

Cardiac Rehabilitation and Risk of Incident Atrial Fibrillation in Patients With Coronary Artery Disease

BackgroundPatients with coronary artery disease (CAD) are at risk for developing atrial fibrillation (AF). Whether attending a cardiac rehabilitation (CR) program can attenuate this risk is unclear.MethodsThis retrospective cohort study included patients who were free of pre-existing AF and referred to CR after coronary revascularization between April 2004 and March 2015 in Calgary, Canada. Patients with incident AF were identified using administrative data and the local electrocardiogram repository. Exposure variables and covariates were extracted from electronic medical records of a CR program and a clinical registry.ResultsThe study included 11,662 patients (mean age [standard deviation], 60.9 [10.9] years; male, 80.6%). In a median follow-up of 4.8 years, the cumulative incidence rate of AF was 1.04 per 100 person-years. There was no association between completion of CR and the risk of incident AF after adjusting for baseline characteristics (hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.83-1.15). However, each higher metabolic equivalent (MET) of baseline cardiorespiratory fitness (CRF) and each MET gain in CRF following CR were independently associated with a 12% (95% CI, 6%-18%) and 18% (95% CI, 6%-28%) lower relative risk of incident AF, respectively. The risk of incident AF declined progressively, with the baseline CRF increasing up to 9.0 peak METs and with the 12-week CRF increasing up to 10.3 peak METs; beyond these peak MET levels, benefits plateaued.ConclusionsCompletion of CR alone was not associated with a lower risk of incident AF. However, higher baseline CRF and greater CRF improvement had dose-dependent protective effects.     

Characterization of Salivary Microbiota in Patients with Atherosclerotic Cardiovascular Disease: A Case-Control Study

Aims: Oral bacteria have been reported to be associated with the pathogenesis of atherosclerosis; however, the relationship between the oral microbiota and atherosclerosis remains unclear. The present study aimed to investigate whether or not salivary microbiota of patients with atherosclerotic cardiovascular disease (ACVD) differs from that of subjects without ACVD, and to characterize the salivary microbiota of patients with ACVD. Methods: This study included 43 patients with ACVD and 86 age- and sex-matched non-ACVD individuals. 16S rRNA metagenomic analysis were performed using DNA isolated from the saliva samples of the participants. To select unique operational taxonomic unit (OTU) sets of ACVD, we conducted the random forest algorithm in machine learning, followed by confirmation via 10-fold cross-validation Results: There was no difference in richness or evenness between the ACVD and non-ACVD groups (alpha diversity; observed OTU index, p =0.503; Shannon’s index, p =0.478). However, significant differences were found in the overall salivary microbiota structure (beta diversity; unweighted UniFrac distances, p =0.001; weighted UniFrac distances, p =0.001). The Actinobacteria phylum was highly abundant in patients with ACVD, while the Bacteroidetes phylum was less abundant. The random forest classifier identified 43 OTUs as an optimal marker set of ACVD. In a 10-fold cross validation using the validation data, an area under the curve (AUC) of 0.933 (95% CI, 0.855–1.000) was obtained. Conclusions: The salivary microbiota in patients with ACVD was distinct from that of non-ACVD individuals, indicating that the salivary microbiota may be related to ACVD.     

冠心病患者外周血白细胞脂蛋白脂酶mRNA的表达

为探讨冠心病患者外周血白细胞脂蛋白脂酶mRNA表达与冠状动脉变程度的关系及意义。用冠状动脉造影后半定量分析获得冠状动脉病变程度,外周血白细胞脂蛋白脂酶mRNA表达用逆转录聚合酶链反应测定,结果发现,冠心病患者各组及正常对照组外周血白细胞中均能检测到特异的脂蛋白脂酶mRNA逆转录聚合酶链反应产物,各组间脂蛋白脂酶mRNA逆转录聚合酶链反应产物测定值差异无显著性（P＞0．05）,冠心病患者中,血甘油三酯水平高者,与甘油三酯水平正常者比较,脂蛋白脂酶mRNA逆转录聚合酶反应产物测定值差异无显著性（P＞0．05）,冠心病患者用肝素前后各组脂蛋白脂酶mRNA逆转录聚合酶链反应产物测定值差异无显著性（P＜0．05）;用肝素后只有血甘油三酯水平低于用肝素前（P＜0．05）,结果提示外周血白细胞脂蛋白脂酶mRNA表达与冠状动脉病变程度无关,肝素无刺激外周血白细胞脂蛋白脂酶mRNA表达的作用。     

Cardiac Rehabilitation Programs Improve Metabolic Parameters in Patients With the Metabolic Syndrome and Coronary Heart Disease

J Clin Hypertens (Greenwich). This study was performed to determine the effectiveness of a cardiac rehabilitation and exercise training program on metabolic parameters and coronary risk factors in patients with the metabolic syndrome and coronary heart disease. The study involved 642 patients with coronary heart disease. Of them, 171 (26.7%) fulfilled criteria for the metabolic syndrome. Clinical data, laboratory tests, and exercise testing were performed before and after the program, which lasted 2 to 3 months. Except for waist circumference, there were no significant differences between groups; blood pressure, high-density lipoprotein cholesterol, triglycerides, and fasting glucose improvements during the follow-up were higher in patients with the metabolic syndrome (all P<.001). At study end, in patients with the metabolic syndrome, functional capacity increased by 26.45% ( P<.001), as measured by metabolic equivalents, with a slight increase of 1.25% ( P=not significant) in the double product. Patients with the metabolic syndrome who took part in this secondary prevention program reported improvements in cardiovascular risk profile and functional capacity.     

近6年冠心病患者危险因素变化调查

目的评价近6年在浙江大学医学院附属第一医院住院的冠心病患者合并心血管病危险因素的变化情况。方法对2000年和2006年因冠心病住院的患者的住院资料进行分析比较。统计分析7个主要的危险因素。结果与2000年相比,2006年冠心病患者中(1)高血压患病率在男性和女性患者中分别升高了7.8%(P>0.05)和4.5%(P>0.05);男性患者入院时收缩压、舒张压水平分别下降4.3mmHg(P<0.05)和2.8mmHg(P<0.01)。(2)血脂异常在男女两组患者分别升高10.3%和7.1%(P<0.01);血清总TC水平分别下降了0.7mmol/L(P<0.01)和0.4mmol/L(P>0.05);血清TG水平分别上升了0.2mmol/L(P>0.05)和0.2mmol/L(P>0.05);血清HDL-C水平男性组下降了0.1mmol/L(P<0.05)。(3)糖尿病患病率男女分别上升10.3%(P<0.01)和17.7%(P<0.05);空腹血糖水平在男性患者中下降了0.2mmol/L(P>0.05)。(4)有心血管病家族史的比例分别上升11.5%(P<0.01)和12.7%(P<0.05)。结论与2000年相比,2006年冠心病患者合并心血管病危险因素明显增加。男性患者一些危险因素水平基本控制在正常范围,女性患者各个危险因素则未得到控制。     

The Distinctive Nature of Atherosclerotic Vascular Disease in Diabetes: Pathophysiological and Morphological Insights

As the incidence of diabetes mellitus continues to rise, parallel increases in the rates of diabetic atherosclerotic vascular disease are projected to impart major health and socioeconomic challenges for authorities worldwide. Diabetes results in a proatherogenic phenotype, manifesting in an accelerated, diffuse, polyvascular fashion. In this review, we highlight the pathophysiological and morphological hallmarks of diabetic atherosclerosis.     

Cardiac Rehabilitation During the COVID-19 Era: Guidance on Implementing Virtual Care

Cardiac rehabilitation programs across Canada have suspended in-person services as a result of large-scale physical distancing recommendations designed to flatten the COVID-19 pandemic curve. Virtual cardiac rehabilitation (VCR) offers an alternate mechanism of care delivery, capable of providing similar patient outcomes and safety profiles compared with centre-based programs. To minimize care gaps, all centres should consider developing and implementing a VCR program. The process of this rapid implementation, however, can be daunting. Centres should initially focus on the collation, utilization, and repurposing of existing resources, equipment, and technology. Once established, programs should then focus on ensuring that quality indicators are met and care processes are protocolized. This should be followed by the development of sustainable VCR solutions to account for care gaps that existed before COVID-19, and to improve cardiac rehabilitation delivery, moving forward. This article reviews the potential challenges and obstacles of this process and aims to provide pragmatic guidance to aid clinicians and administrators during this challenging time.     

The Effect of Cardiac Rehabilitation Attendance on Sexual Activity Outcomes in Cardiovascular Disease Patients: A Systematic Review

Background

Decreased sexual activity (SA) is a common problem in patients with cardiovascular disease (CVD). Although there is evidence that cardiac rehabilitation (CR) is effective in improving physical outcomes and overall quality of life, its effects on SA remain unclear. In this systematic review we assessed the association between CR attendance and SA outcomes in adults with CVD.