Chayakrit Krittanawong

Artificial intelligence (AI) is a field of computer science that aims to mimic human thought processes, learning capacity, and knowledge storage. AI techniques have been applied in cardiovascular medicine to explore novel genotypes and phenotypes in existing diseases, improve the quality of patient care, enable cost-effectiveness, and reduce readmission and mortality rates. Over the past decade, several machine-learning techniques have been used for cardiovascular disease diagnosis and prediction. Each problem requires some degree of understanding of the problem, in terms of cardiovascular medicine and statistics, to apply the optimal machine-learning algorithm. In the near future, AI will result in a paradigm shift toward precision cardiovascular medicine. The potential of AI in cardiovascular medicine is tremendous; however, ignorance of the challenges may overshadow its potential clinical impact. This paper gives a glimpse of AI's application in cardiovascular clinical care and discusses its potential role in facilitating precision cardiovascular medicine.

Abstract Deep learning (DL) is a branch of machine learning (ML) showing increasing promise in medicine, to assist in data classification, novel disease phenotyping and complex decision making. Deep learning is a form of ML typically implemented via multi-layered neural networks. Deep learning has accelerated by recent advances in computer hardware and algorithms and is increasingly applied in e-commerce, finance, and voice and image recognition to learn and classify complex datasets. The current medical literature shows both strengths and limitations of DL. Strengths of DL include its ability to automate medical image interpretation, enhance clinical decision-making, identify novel phenotypes, and select better treatment pathways in complex diseases. Deep learning may be well-suited to cardiovascular medicine in which haemodynamic and electrophysiological indices are increasingly captured on a continuous basis by wearable devices as well as image segmentation in cardiac imaging. However, DL also has significant weaknesses including difficulties in interpreting its models (the ‘black-box’ criticism), its need for extensive adjudicated (‘labelled’) data in training, lack of standardization in design, lack of data-efficiency in training, limited applicability to clinical trials, and other factors. Thus, the optimal clinical application of DL requires careful formulation of solvable problems, selection of most appropriate DL algorithms and data, and balanced interpretation of results. This review synthesizes the current state of DL for cardiovascular clinicians and investigators, and provides technical context to appreciate the promise, pitfalls, near-term challenges, and opportunities for this exciting new area.

Several machine learning (ML) algorithms have been increasingly utilized for cardiovascular disease prediction. We aim to assess and summarize the overall predictive ability of ML algorithms in cardiovascular diseases. A comprehensive search strategy was designed and executed within the MEDLINE, Embase, and Scopus databases from database inception through March 15, 2019. The primary outcome was a composite of the predictive ability of ML algorithms of coronary artery disease, heart failure, stroke, and cardiac arrhythmias. Of 344 total studies identified, 103 cohorts, with a total of 3,377,318 individuals, met our inclusion criteria. For the prediction of coronary artery disease, boosting algorithms had a pooled area under the curve (AUC) of 0.88 (95% CI 0.84-0.91), and custom-built algorithms had a pooled AUC of 0.93 (95% CI 0.85-0.97). For the prediction of stroke, support vector machine (SVM) algorithms had a pooled AUC of 0.92 (95% CI 0.81-0.97), boosting algorithms had a pooled AUC of 0.91 (95% CI 0.81-0.96), and convolutional neural network (CNN) algorithms had a pooled AUC of 0.90 (95% CI 0.83-0.95). Although inadequate studies for each algorithm for meta-analytic methodology for both heart failure and cardiac arrhythmias because the confidence intervals overlap between different methods, showing no difference, SVM may outperform other algorithms in these areas. The predictive ability of ML algorithms in cardiovascular diseases is promising, particularly SVM and boosting algorithms. However, there is heterogeneity among ML algorithms in terms of multiple parameters. This information may assist clinicians in how to interpret data and implement optimal algorithms for their dataset.

Physicians in everyday clinical practice are under pressure to innovate faster than ever because of the rapid, exponential growth in healthcare data. “Big data” refers to extremely large data sets that cannot be analyzed or interpreted using traditional data processing methods. In fact, big data itself is meaningless, but processing it offers the promise of unlocking novel insights and accelerating breakthroughs in medicine—which in turn has the potential to transform current clinical practice. Physicians can analyze big data, but at present it requires a large amount of time and sophisticated analytic tools such as supercomputers. However, the rise of artificial intelligence (AI) in the era of big data could assist physicians in shortening processing times and improving the quality of patient care in clinical practice. This editorial provides a glimpse at the potential uses of AI technology in clinical practice and considers the possibility of AI replacing physicians, perhaps altogether. Physicians diagnose diseases based on personal medical histories, individual biomarkers, simple scores (e.g., CURB-65, MELD), and their physical examinations of individual patients. In contrast, AI can diagnose diseases based on a complex algorithm using hundreds of biomarkers, imaging results from millions of patients, aggregated published clinical research from PubMed, and thousands of physician's notes from electronic health records (EHRs). While AI could assist physicians in many ways, it is unlikely to replace physicians in the foreseeable future. Let us look at the emerging uses of AI in medicine.

Ambulatory monitoring is increasingly important for cardiovascular care but is often limited by the unpredictability of cardiovascular events, the intermittent nature of ambulatory monitors and the variable clinical significance of recorded data in patients. Technological advances in computing have led to the introduction of novel physiological biosignals that can increase the frequency at which abnormalities in cardiovascular parameters can be detected, making expert-level, automated diagnosis a reality. However, use of these biosignals for diagnosis also raises numerous concerns related to accuracy and actionability within clinical guidelines, in addition to medico-legal and ethical issues. Analytical methods such as machine learning can potentially increase the accuracy and improve the actionability of device-based diagnoses. Coupled with interoperability of data to widen access to all stakeholders, seamless connectivity (an internet of things) and maintenance of anonymity, this approach could ultimately facilitate near-real-time diagnosis and therapy. These tools are increasingly recognized by regulatory agencies and professional medical societies, but several technical and ethical issues remain. In this Review, we describe the current state of cardiovascular monitoring along the continuum from biosignal acquisition to the identification of novel biosensors and the development of analytical techniques and ultimately to regulatory and ethical issues. Furthermore, we outline new paradigms for cardiovascular monitoring.

Abstract Background and Objectives Since publishing successful clinical trial results of mRNA coronavirus disease 2019 (COVID‐19) vaccines in December 2020, multiple reports have arisen about cardiovascular complications following the mRNA vaccination. This study provides an in‐depth account of various cardiovascular adverse events reported after the mRNA vaccines' first or second dose including pericarditis/myopericarditis, myocarditis, hypotension, hypertension, arrhythmia, cardiogenic shock, stroke, myocardial infarction/STEMI, intracranial hemorrhage, thrombosis (deep vein thrombosis, cerebral venous thrombosis, arterial or venous thrombotic events, portal vein thrombosis, coronary thrombosis, microvascular small bowel thrombosis), and pulmonary embolism. Methods A systematic review of original studies reporting confirmed cardiovascular manifestations post‐mRNA COVID‐19 vaccination was performed. Following the PRISMA guidelines, electronic databases (PubMed, PMC NCBI, and Cochrane Library) were searched until January 2022. Baseline characteristics of patients and disease outcomes were extracted from relevant studies. Results A total of 81 articles analyzed confirmed cardiovascular complications post‐COVID‐19 mRNA vaccines in 17,636 individuals and reported 284 deaths with any mRNA vaccine. Of 17,636 cardiovascular events with any mRNA vaccine, 17,192 were observed with the BNT162b2 (Pfizer−BioNTech) vaccine, 444 events with mRNA‐1273 (Moderna). Thrombosis was frequently reported with any mRNA vaccine ( n = 13,936), followed by stroke ( n = 758), myocarditis ( n = 511), myocardial infarction ( n = 377), pulmonary embolism ( n = 301), and arrhythmia ( n = 254). Stratifying the results by vaccine type showed that thrombosis (80.8%) was common in the BNT162b2 cohort, while stroke (39.9%) was common with mRNA‐1273 for any dose. The time between the vaccination dosage and the first symptom onset averaged 5.6 and 4.8 days with the mRNA‐1273 vaccine and BNT162b2, respectively. The mRNA‐1273 cohort reported 56 deaths compared to the 228 with BNT162b2, while the rest were discharged or transferred to the ICU. Conclusion Available literature includes more studies with the BNT162b2 vaccine than mRNA‐1273. Future studies must report mortality and adverse cardiovascular events by vaccine types.

PM2.5 is a frequently studied particulate matter metric, due to its wide range of identified overall adverse health effects, particularly cardiovascular health risks. However, there are no clear clinical practice guidelines for air pollution in regard to the prevention of cardiovascular health risks, since most of the current medical guidelines for CVD focus on metabolic risk factors such as hyperlipidemia or diabetes. We sought to determine the relationship between PM2.5 and cardiovascular disease, cardiovascular events, and all-cause mortality by performing a systematic review and meta-analysis. We searched Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from the database inception to December 2022 for studies that reported an association between PM2.5 and cardiovascular disease, cardiovascular events, and all-cause mortality. We used the DerSimonian & Laird random-effects method to pool hazard ratios or risk ratios separately from the included studies. Of the total 18 prospective studies, 7,300,591 individuals were followed for a median follow-up of 9 years. Compared to low long-term exposure to PM 2.5 levels, an increase in exposure to PM 2.5 levels resulted in an increase in all-cause mortality (HR 1.08 95% CI of 1.05-1.11, P < 0.05). Similarly, when compared to a low long-term exposure to PM 2.5 levels, an increase in exposure to PM 2.5 levels resulted in an increase in cardiovascular disease (HR 1.09, 95% CI of 1.00-1.18, P < 0.05) and an increase in cardiovascular disease mortality (HR 1.12, 95% CI of 1.07-1.18, P < 0.05). Increased exposure to PM 2.5 levels is significantly associated with an increased risk of all-cause mortality, cardiovascular disease, and cardiovascular disease mortality. Although federal primary and secondary standards are in place, those standards are not low enough to prevent CVD health effects. Clinicians should emphasize PM2.5 as a modifiable CV risk factors for their patients to potentially reduce the development of CV complications. A clinical action guideline is needed specifically for air pollution effects on CVD, and how to mitigate them.

A shorter sleep duration has been identified as a risk factor for cardiovascular diseases and increased mortality. It has been hypothesized that a short sleep duration may be linked to changes in ghrelin and leptin production, leading to an alteration of stress hormone production. Here, we conducted a systematic review and meta-analysis to investigate the potential relationship between a sleep duration and cardiovascular disease mortality.We conducted a comprehensive search of Ovid Medline In-Process and other non-indexed citations, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, and Scopus from database inception to March 2017. Observational studies were included if the studies reported hazard ratios or odds ratios of the associations between sleep durations (short and long) and cardiovascular disease mortality. Data were extracted by a reviewer and then reviewed by two separate reviewers. Conflicts were resolved through consensus. Using the DerSimonian and Laird random effects models, we calculated pooled hazard ratios and pooled odds ratios with 95% confidence intervals (CI). Subgroup analyses were performed to explore potential sources of heterogeneity. The quality of the included studies and publication bias were assessed.In total, our meta-analysis included 19 studies (31 cohorts) with a total of 816,995 individuals with 42,870 cardiovascular disease mortality cases. In pooled analyses, both short (risk ratio 1.19; 95% CI 1.13 to 1.26, P<0.001, I2=30.7, Pheterogeneity=0.034), and long (risk ratio 1.37; 95% CI 1.23 to 1.52, P<0.001, I2=79.75, Pheterogeneity<0.001) sleep durations were associated with a greater risk of cardiovascular disease mortality.Both short (<7 hours) and long sleep durations (>9 hours) can increase the risk of overall cardiovascular disease mortality, particularly in Asian populations and elderly individuals. Future epidemiological studies would ideally include objective sleep measurements, rather than self-report measures, and all potential confounders, such as genetic variants.

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of myocardial infarction; however, the role of cardiac rehabilitation (CR) for patients with SCAD has not been well defined. To further understand CR in patients with SCAD, we studied a large cohort of patients with confirmed SCAD enrolled in the Mayo Clinic SCAD Registry from January 2010 to December 2014 (n = 354). Demographics, clinical characteristics, mental health status, and details about CR participation and experience were collected through medical record review and questionnaires. Participants at time of SCAD were 46 ± 10 years old; 96% were women. Most (76%) attended ≥1 CR sessions, averaging 18 ± 12 sessions. Most reported CR-related physical and emotional benefits (82% and 75%, respectively). Of the CR nonparticipants, 57 of 85 reported not participating because CR was not recommended by their health care provider. Other reasons included inadequate transportation (10 of 85), no insurance coverage (7 of 85), cost (2 of 85), no energy (2 of 85), being too ill (2 of 85), and miscellaneous comments (5 of 85). In conclusion, 3 of 4 of patients with SCAD participated in CR, most of whom reported benefit. Lack of recommendation for CR by a health care provider was the primary reason patients did not participate. Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of myocardial infarction; however, the role of cardiac rehabilitation (CR) for patients with SCAD has not been well defined. To further understand CR in patients with SCAD, we studied a large cohort of patients with confirmed SCAD enrolled in the Mayo Clinic SCAD Registry from January 2010 to December 2014 (n = 354). Demographics, clinical characteristics, mental health status, and details about CR participation and experience were collected through medical record review and questionnaires. Participants at time of SCAD were 46 ± 10 years old; 96% were women. Most (76%) attended ≥1 CR sessions, averaging 18 ± 12 sessions. Most reported CR-related physical and emotional benefits (82% and 75%, respectively). Of the CR nonparticipants, 57 of 85 reported not participating because CR was not recommended by their health care provider. Other reasons included inadequate transportation (10 of 85), no insurance coverage (7 of 85), cost (2 of 85), no energy (2 of 85), being too ill (2 of 85), and miscellaneous comments (5 of 85). In conclusion, 3 of 4 of patients with SCAD participated in CR, most of whom reported benefit. Lack of recommendation for CR by a health care provider was the primary reason patients did not participate.

Artificial intelligence (AI) holds promise for cardiovascular medicine but is limited by a lack of large, heterogeneous and granular data sets. Blockchain provides secure interoperability between siloed stakeholders and centralized data sources. We discuss integration of blockchain with AI for data-centric analysis and information flow, its current limitations and potential cardiovascular applications.

The development of artificial intelligence (AI) has increased dramatically in the last 20 years, with clinical applications progressively being explored for most of the medical specialties. The field of gastroenterology and hepatology, substantially reliant on vast amounts of imaging studies, is not an exception. The clinical applications of AI systems in this field include the identification of premalignant or malignant lesions (e.g., identification of dysplasia or esophageal adenocarcinoma in Barrett's esophagus, pancreatic malignancies), detection of lesions (e.g., polyp identification and classification, small-bowel bleeding lesion on capsule endoscopy, pancreatic cystic lesions), development of objective scoring systems for risk stratification, predicting disease prognosis or treatment response [e.g., determining survival in patients post-resection of hepatocellular carcinoma), determining which patients with inflammatory bowel disease (IBD) will benefit from biologic therapy], or evaluation of metrics such as bowel preparation score or quality of endoscopic examination. The objective of this comprehensive review is to analyze the available AI-related studies pertaining to the entirety of the gastrointestinal tract, including the upper, middle and lower tracts; IBD; the hepatobiliary system; and the pancreas, discussing the findings and clinical applications, as well as outlining the current limitations and future directions in this field.

Objective Despite an upsurge in the incidence of atherosclerotic cardiovascular diseases (ASCVD) among young adults, the attributable risk of recreational substance use among young patients has been incompletely evaluated. We evaluated the association of all recreational substances with premature and extremely premature ASCVD. Methods In a cross-sectional analysis using the 2014–2015 nationwide Veterans Affairs Healthcare database and the Veterans wIth premaTure AtheroscLerosis (VITAL) registry, patients were categorised as having premature, extremely premature or non-premature ASCVD. Premature ASCVD was defined as having first ASCVD event at age &lt;55 years for men and &lt;65 years for women. Extremely premature was defined as having first ASCVD event at age &lt;40 years while non-premature ASCVD was defined as having first ASCVD event at age ≥55 years for men and ≥65 years for women. Patients with premature ASCVD (n=135 703) and those with extremely premature ASCVD (n=7716) were compared against patients with non-premature ASCVD (n=1 112 455). Multivariable logistic regression models were used to study the independent association of all recreational substances with premature and extremely premature ASCVD. Results Compared with patients with non-premature ASCVD, patients with premature ASCVD had a higher use of tobacco (62.9% vs 40.6%), alcohol (31.8% vs 14.8%), cocaine (12.9% vs 2.5%), amphetamine (2.9% vs 0.5%) and cannabis (12.5% vs 2.7%) (p&lt;0.01 for all comparisons). In adjusted models, the use of tobacco (OR 1.97, 95% CI 1.94 to 2.00), alcohol (OR 1.50, 95% CI 1.47 to 1.52), cocaine (OR 2.44, 95% CI 2.38 to 2.50), amphetamine (OR 2.74, 95% CI 2.62 to 2.87), cannabis (OR 2.65, 95% CI 2.59 to 2.71) and other drugs (OR 2.53, 95% CI 2.47 to 2.59) was independently associated with premature ASCVD. Patients with polysubstance use had a graded response with the highest risk (~9-fold) of premature ASCVD among patients with use of ≥4 recreational substances. Similar trends were observed among patients with extremely premature ASCVD. Gender interactions with substance use were significant (p-interaction &lt;0.05), with recreational substance use and premature ASCVD showing stronger associations among women than in men with premature ASCVD. Conclusions All subgroups of recreational substances were independently associated with a higher likelihood of premature and extremely premature ASCVD. Recreational substance use confers a greater magnitude of risk for premature ASCVD among women. A graded response relationship exists between increasing number of recreational substances used and higher likelihood of early-onset ASCVD.

Emerging data showed patients with chronic inflammatory disorders, including inflammatory bowel disease, are more likely to develop atherosclerotic cardiovascular diseases, heart failure, and atrial fibrillation. This article aims to review the evidence of those associations.PubMed was searched from inception to January 2022 using the keywords, including inflammatory bowel diseases, Crohn disease, ulcerative colitis, atherosclerotic cardiovascular disease, coronary artery disease, cardiovascular disease, atrial fibrillation, heart failure, and premature coronary artery disease. Relevant literature, including retrospective/prospective cohort studies, clinical trials, meta-analyses, and guidelines, were reviewed and summarized.Both ulcerative colitis and Crohn disease are associated with an increased risk of atherosclerotic cardiovascular diseases, cerebrovascular accidents, premature coronary artery disease, and atrial fibrillation. Ulcerative colitis is associated with an increased risk of heart failure. The increased atrial fibrillation occurred during inflammatory bowel disease flares and persistent activity but not during periods of remission. Hypotheses for the mechanism underlying the association of inflammatory bowel disease and atherosclerotic cardiovascular diseases include shared risk factors (ie, obesity, diabetes, smoking, diet) and pathophysiology (gut microbiome dysfunction) or adverse effects from inflammatory bowel disease itself or its treatment (ie, chronic inflammation, dyslipidemia, thrombocytosis, steroids).Inflammatory bowel disease is associated with an increased risk of atherosclerotic cardiovascular diseases, heart failure, and atrial fibrillation. A multidisciplinary team with gastroenterologists and cardiologists is needed to optimize the care for patients with inflammatory bowel disease and associated cardiac diseases.

Cardiovascular disease remains the leading worldwide cause of mortality. There has been increased awareness of the impact of psychological health on cardiovascular disease . In particular, major depression has been linked to increased all-cause mortality, development of cardiovascular disease, and worse outcomes in those with existing cardiovascular disease . We conducted a meta-analysis assessing the incidence of cardiovascular disease and cardiovascular disease outcomes among those with major depressive disorder. Among 35 studies of 1,957,621 individuals, depression was associated with increased risk of incident stroke (HR 1.13, [1.00-1.28]), myocardial infarction (HR 1.28, [1.14-1.45]), congestive heart failure (HR 1.04, [1.00-1.09]), or any cardiovascular disease (HR 1.16, [1.04-1.30]). Depression was associated with increased risk of all-cause mortality (HR 1.43, [1.27-1.60]), cardiovascular disease mortality (HR 1.44, [1.27-1.63]), and congestive heart failure mortality (HR 3.20, [1.29-7.94]). Depression has a significant negative impact on development of cardiovascular disease and on cardiovascular disease outcomes. Further efforts to understand and mitigate these impacts are prudent.

Standard measures for the clinical assessment of right atrial (RA) function are lacking. In this systematic review and meta-analysis, the authors sought to report a reference range for RA deformation parameters in healthy subjects and to identify factors that contribute to reported variations. The authors conducted a comprehensive search of MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; Embase; Scopus; and the Cochrane Central Register of Controlled Trials from database inception through October 2021. Studies were included if they reported RA strain or strain rate (SR) using 2-dimensional speckle-tracking echocardiography in healthy volunteers or apparently healthy control patients. Data were extracted by 1 reviewer and then reviewed by 2 independent reviewers. Conflicts were resolved through consensus. Data were combined using the method developed by Siegel and adjusted using the restricted maximum likelihood random-effects model. The normal range was defined as the 95% CI of the mean. Heterogeneity was assessed by the Cochran Q-statistic and the inconsistency index (I2). The quality of the included studies and publication bias were assessed. Effects of clinical variables were sought in a metaregression. The search identified 4,111 subjects from 21 studies. The average RA reservoir strain was 44% (95% CI: 25%-63%), contractile strain was 17% (95% CI: 2%-32%), and conduit strain was 18% (95% CI: 7%-28%), with significant between-study heterogeneity and inconsistency. The systolic SR was 2.1 s-1 (95% CI: 0.9-3.4 s-1), early-diastolic SR was −2.0 s-1 (95% CI: −3.3 to −0.8 s-1), and late-diastolic SR was −1.9 s-1 (95% CI: −2.4 to −1.3 s-1), with nonsignificant heterogeneity and inconsistency. Ranges remained wide in healthy volunteers. The metaregression identified only age as significantly associated with systolic SR and no other significant determinants of variation among normal ranges of strain. There are wide reference ranges for RA deformation, and these may limit the utility of this test in clinical practice.

Cardiovascular (CV) disease (CVD) is the leading cause of global morbidity and mortality, and low levels of physical activity (PA) is a leading independent predictor of poor CV health and associated with an increased prevalence of risk factors that predispose to CVD development. In this review, we evaluate the benefits of exercise on CV health. We discuss the CV adaptations to exercise, focusing on the physiological changes in the heart and vasculature. We review the impact and benefits of exercise on specific CV prevention, including type II diabetes, hypertension, hyperlipidemia, coronary artery disease, and heart failure, in addition to CVD-related and all-cause mortality. Lastly, we evaluate the current PA guidelines and various modes of exercise, assessing the current literature for the effective regimens of PA that improve CVD outcomes.

Generative Artificial Intelligence (AI) tools have experienced rapid development over the last decade and are gaining increasing popularity as assistive models in academic writing. However, the ability of AI to generate reliable and accurate research articles is a topic of debate. Major scientific journals have issued policies regarding the contribution of AI tools in scientific writing. We conducted a review of the author and peer reviewer guidelines of the top 25 Cardiology and Cardiovascular Medicine journals as per the 2023 SCImago rankings. Data were obtained though reviewing journal websites and directly emailing the editorial office. Descriptive data regarding journal characteristics were coded on SPSS. Subgroup analyses of the journal guidelines were conducted based on the publishing company policies. Our analysis revealed that all scientific journals in our study permitted the documented use of AI in scientific writing with certain limitations as per ICMJE recommendations. We found that AI tools cannot be included in the authorship or be used for image generation, and that all authors are required to assume full responsibility of their submitted and published work. The use of generative AI tools in the peer review process is strictly prohibited. Guidelines regarding the use of generative AI in scientific writing are standardized, detailed, and unanimously followed by all journals in our study according to the recommendations set forth by international forums. It is imperative to ensure that these policies are carefully followed and updated to maintain scientific integrity.

Background & AimsNonselective β-blockers (NSBBs), given to reduce the risk of variceal bleeding, have been associated with increased mortality in patients with cirrhosis and refractory ascites in some, but not all, studies. We performed a systematic review and meta-analysis to evaluate the effect of NSBBs on all-cause mortality in patients with cirrhosis and refractory ascites.MethodsWe performed a comprehensive search of MEDLINE, Embase, Web of Science, and Scopus databases through January 2015, supplemented with a manual search. Trial-specific risk ratios (RRs) were pooled using the random-effects model.ResultsOur analysis included 3 randomized control trials and 8 observational studies of propranolol, carvedilol, nadolol, and metoprolol, reporting 1206 deaths among 3145 patients with ascites. The control groups received other interventions to prevent variceal bleeding. NSBB use was not associated with increased all-cause mortality in all patients with ascites (RR, 0.95; 95% confidence interval [CI], 0.67–1.35); nonrefractory ascites alone (RR, 0.96; 95% CI, 0.50–1.82), or refractory ascites alone (RR, 0.95; 95% CI, 0.57–1.61). Results were similar in randomized controlled trials and observational studies. Use of NSBBs was not associated with increased mortality at 6, 12, 18, and 24 months. Overall, the included studies had a medium to high risk of bias, except for 3 clinical trials in which the risk of biased was determined to be low.ConclusionsThe use of NSBBs was not associated with a significant increase in all-cause mortality in patients with cirrhosis and ascites or refractory ascites. Certainty in the available estimates is low; a randomized trial of only patients with ascites is needed to answer this question. This meta-analysis does not support the position that NSBBs routinely be withheld from patients with ascites. Nonselective β-blockers (NSBBs), given to reduce the risk of variceal bleeding, have been associated with increased mortality in patients with cirrhosis and refractory ascites in some, but not all, studies. We performed a systematic review and meta-analysis to evaluate the effect of NSBBs on all-cause mortality in patients with cirrhosis and refractory ascites. We performed a comprehensive search of MEDLINE, Embase, Web of Science, and Scopus databases through January 2015, supplemented with a manual search. Trial-specific risk ratios (RRs) were pooled using the random-effects model. Our analysis included 3 randomized control trials and 8 observational studies of propranolol, carvedilol, nadolol, and metoprolol, reporting 1206 deaths among 3145 patients with ascites. The control groups received other interventions to prevent variceal bleeding. NSBB use was not associated with increased all-cause mortality in all patients with ascites (RR, 0.95; 95% confidence interval [CI], 0.67–1.35); nonrefractory ascites alone (RR, 0.96; 95% CI, 0.50–1.82), or refractory ascites alone (RR, 0.95; 95% CI, 0.57–1.61). Results were similar in randomized controlled trials and observational studies. Use of NSBBs was not associated with increased mortality at 6, 12, 18, and 24 months. Overall, the included studies had a medium to high risk of bias, except for 3 clinical trials in which the risk of biased was determined to be low. The use of NSBBs was not associated with a significant increase in all-cause mortality in patients with cirrhosis and ascites or refractory ascites. Certainty in the available estimates is low; a randomized trial of only patients with ascites is needed to answer this question. This meta-analysis does not support the position that NSBBs routinely be withheld from patients with ascites.

The pathophysiology of spontaneous coronary artery dissection (SCAD) is heterogeneous, associated with systemic arteriopathies and inflammatory diseases, and often compounded by environmental precipitants, genetics, or stressors. However, the frequency of these associated conditions with SCAD on a population level remains unknown. Therefore, the objective of this analysis was to evaluate heterogeneous phenotypes of SCAD in the United States using data from the Nationwide Inpatient Sample collected from January 1, 2004, to September 31, 2015. Among 66,360 patients diagnosed with SCAD, the mean age was 63.1 ± 13.2 years and 44.2% were women. A total of 3,415 (5.14%) had depression, 670 (1.0%) had rheumatoid arthritis, 640 (0.96%) had anxiety, 545 (0.82%) had a migraine disorder, 440 (0.66%) used steroids, 385 (0.58%) had malignant hypertension, 280 (0.42%) had systemic lupus erythematosus, 250 (0.38%) had cocaine abuse, 215 (0.32%) had hypertensive heart or renal disease, 130 (0.19%) had coronary spasm, 105 (0.16%) had fibromuscular dysplasia, 85 (0.13%) had Crohn's disease, 75 (0.11%) had celiac disease, 60 (0.09%) had adult autosomal dominant polycystic kidney disease, 60 (0.09%) had hormone replacement therapy, 55 (0.08%) had sarcoidosis, 55 (0.08%) had amphetamine abuse, 15 (0.02%) had granulomatosis polyangiitis, 10 (0.02%) had α1-antitrypsin deficiency, 10 (0.02%) had Marfan syndrome, 10 (0.02%) had Ehlers-Danlos syndrome, 10 (0.02%) had Kawasaki disease, 10 (0.02%) had polyarteritis nodosa, and 5 (0.01%) had multiparity. In conclusion, most cases of SCAD had no apparent concomitant arteriopathy, inflammatory disorder, or evident risk factor.

Hyponatremia is a very common electrolyte abnormality, associated with poor short- and long-term outcomes in patients with heart failure (HF). Two opposite processes can result in hyponatremia in this setting: Volume overload with dilutional hypervolemic hyponatremia from congestion, and hypovolemic hyponatremia from excessive use of natriuretics. These two conditions require different therapeutic approaches. While sodium in the form of normal saline can be lifesaving in the second case, the same treatment would exacerbate hyponatremia in the first case. Hypervolemic hyponatremia in HF patients is multifactorial and occurs mainly due to the persistent release of arginine vasopressin (AVP) in the setting of ineffective renal perfusion secondary to low cardiac output. Fluid restriction and loop diuretics remain mainstay treatments for hypervolemic/ dilutional hyponatremia in patients with HF. In recent years, a few strategies, such as AVP antagonists (Tolvaptan, Conivaptan, and Lixivaptan), and hypertonic saline in addition to loop diuretics, have been proposed as potentially promising treatment options for this condition. This review aimed to summarize the current literature on pathogenesis and management of hyponatremia in patients with HF.

The 2016 American Heart Association Scientific Statement on sleep duration and cardiovascular risk suggested that optimal sleep duration is critical for cardiovascular health, with both long and short sleep duration associated with adverse health outcomes. We examined the relation between sleep duration and cardiovascular health among the general population in the United States from 2005 to 2016. We sought to investigate associations between sleep duration and the prevalence of coronary artery disease, heart failure (HF), stroke, hypertension, diabetes mellitus (DM), and hyperlipidemia. Using the National Health and Nutrition Examination Survey, we identified all patients with HF, coronary artery disease, hypertension, hyperlipidemia, DM, and stroke from 2005 to 2016. Multivariable logistic regression analyses were performed to adjust for age, sex, body mass index (BMI), marital status, educational level, physical activity, sedentary activity, depression, blood pressure, lipid profiles, and hemoglobin. In total, 32,152 National Health and Nutrition Examination Survey participants responded to the sleep survey. Both short sleepers (<7 hours, n = 12,027) and long sleepers (>9 hours, n = 1,058) were older and more likely to have a higher BMI than optimal sleepers (7 to 9 hours, n = 19,067; all p values <0.05). After adjusting for confounding variables and in comparison to those with optimal sleep duration, short sleep duration was associated with a higher prevalence of previous stroke (odds ratio [OR] 1.45; 95% confidence intervals [CI] 1.23 to 1.70), HF (OR 1.65; 95% CI 1.40 to 1.95), DM (OR 1.35; 95% CI 1.23 to 1.49), and hyperlipidemia (OR 1.12; 95% CI 1.04 to 1.22), whereas long sleep duration was associated with a higher prevalence of previous stroke (OR 1.81; 95% CI 1.37 to 2.34) and HF (OR 1.47; 95% CI 1.08 to 1.97). In conclusion, both long and short sleep durations were associated with poor cardiovascular health in this cross-sectional study.

Twitter offers a potentially novel investigation line to evaluate self-perception and awareness in the context of the public health response to the coronavirus disease (COVID-19) pandemic. Studies have shown that Twitter content may provide crucial insights into the ongoing public health crisis.1,2 However, some studies suggest that Twitter may play an important role in propagating misinformation in previous epidemics such as the Zika, Ebola, and yellow fever virus outbreaks.3-5 In the COVID-19 era, scientists and clinicians use Twitter to echo scientific evidence, especially toward an academic audience.

Introduction Edible mushrooms have a great nutritional value including high protein, essential amino acids, fiber, vitamins (B1, B2, B12, C, and D), minerals (calcium [Ca], potassium [K], magnesium [Mg], sodium [Na], phosphorus [P], copper [Cu], iron [Fe], manganese [Mn], and selenium [Se]), low fatty foods, and sodium. The objective of this systematic review was to determine the relationship between edible mushroom consumption and overall cardiovascular risk. Methods We systematically searched Ovid MEDLINE, Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from database inception from 1966 through August 2020 for observational studies that reported the association between edible mushroom consumption and cardiovascular risk. Two investigators independently reviewed data. Conflicts were resolved through consensus discussion. Results Of 1479 studies, we identified 7 prospective studies. Edible mushroom consumption may have favorable effects on lipid profiles by changing some metabolic markers such as low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, total cholesterol, and triglycerides. Moreover, edible mushroom consumption is probably associated with reduced mean blood pressure. The beneficial overall cardiovascular risk, stroke risk, and coronary artery disease of edible mushroom consumption are not consistent. Conclusions Edible mushroom consumption has not been shown to conclusively affect cardiovascular risk factors to date. However, potential health benefits may exist, including a favorable alteration of lipid profiles and blood pressure reduction.

Considerable controversy remains on the relationship between egg consumption and cardiovascular disease risk. The objective of this systematic review and meta-analysis was to explore the association between egg consumption and overall cardiovascular disease events.We systematically searched Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from database inception in 1966 through January 2020 for observational studies that reported the association between egg consumption and cardiovascular disease events. Two investigators independently reviewed data. Conflicts were resolved through consensus. Random-effects meta-analyses were used. Sources of heterogeneity were analyzed.We identified 23 prospective studies with a median follow-up of 12.28 years. A total of 1,415,839 individuals with a total of 123,660 cases and 157,324 cardiovascular disease events were included. Compared with the consumption of no or 1 egg/day, higher egg consumption (more than 1 egg/day) was not associated with significantly increased risk of overall cardiovascular disease events (pooled hazard ratios, 0.99; 95% confidence interval, 0.93-1.06; P < .001; I² = 72.1%). Higher egg consumption (more than 1 egg/day) was associated with a significantly decreased risk of coronary artery disease (pooled hazard ratios, 0.89; 95% confidence interval, 0.86-0.93; P < .001; I² = 0%), compared with consumption of no or 1 egg/day.Our analysis suggests that higher consumption of eggs (more than 1 egg/day) was not associated with increased risk of cardiovascular disease, but was associated with a significant reduction in risk of coronary artery disease.

Machine learning (ML) and deep learning (DL) can successfully predict high prevalence events in very large databases (big data), but the value of this methodology for risk prediction in smaller cohorts with uncommon diseases and infrequent events is uncertain. The clinical course of spontaneous coronary artery dissection (SCAD) is variable, and no reliable methods are available to predict mortality. Based on the hypothesis that machine learning (ML) and deep learning (DL) techniques could enhance the identification of patients at risk, we applied a deep neural network to information available in electronic health records (EHR) to predict in-hospital mortality in patients with SCAD. We extracted patient data from the EHR of an extensive urban health system and applied several ML and DL models using candidate clinical variables potentially associated with mortality. We partitioned the data into training and evaluation sets with cross-validation. We estimated model performance based on the area under the receiver-operator characteristics curve (AUC) and balanced accuracy. As sensitivity analyses, we examined results limited to cases with complete clinical information available. We identified 375 SCAD patients of which mortality during the index hospitalization was 11.5%. The best-performing DL algorithm identified in-hospital mortality with AUC 0.98 (95% CI 0.97-0.99), compared to other ML models (P < 0.0001). For prediction of mortality using ML models in patients with SCAD, the AUC ranged from 0.50 with the random forest method (95% CI 0.41-0.58) to 0.95 with the AdaBoost model (95% CI 0.93-0.96), with intermediate performance using logistic regression, decision tree, support vector machine, K-nearest neighbors, and extreme gradient boosting methods. A deep neural network model was associated with higher predictive accuracy and discriminative power than logistic regression or ML models for identification of patients with ACS due to SCAD prone to early mortality.

Clinical databases, particularly those composed of big data, face growing security challenges. Blockchain, the open, decentralized, distributed public ledger technology powering cryptocurrency, records transactions securely without the need for third-party verification. In the health care setting, decentralized blockchain networks offer a secure interoperable gateway for clinical research and practice data. Here, we discuss recent advances and potential future directions for the application of blockchain and its integration with artificial intelligence (AI) in cardiovascular medicine. We first review the basic underlying concepts of this technology and contextualise it within the spectrum of current, well known applications. We then consider specific applications for cardiovascular medicine and research in areas such as high-throughput gene sequencing, wearable technologies, and clinical trials. We then evaluate current challenges to effective implementation and future directions. We also summarise the health care applications that can be realised by combining decentralized blockchain computing platforms (for data security) and AI computing (for data analytics). By leveraging high-performance computing and AI capable of securely managing large and rapidly expanding medical databases, blockchain incorporation can provide clinically meaningful predictions, help advance research methodology (eg, via robust AI-blockchain decentralized clinical trials), and provide virtual tools in clinical practice (eg, telehealth, sensory-based technologies, wearable medical devices). Integrating AI and blockchain approaches synergistically amplifies the strengths of both technologies to create novel solutions to serve the objective of providing precision cardiovascular medicine.

Polygenic diseases, which are genetic disorders caused by the combined action of multiple genes, pose unique and significant challenges for the diagnosis and management of affected patients. A major goal of cardiovascular medicine has been to understand how genetic variation leads to the clinical heterogeneity seen in polygenic cardiovascular diseases (CVDs). Recent advances and emerging technologies in artificial intelligence (AI), coupled with the ever-increasing availability of next generation sequencing (NGS) technologies, now provide researchers with unprecedented possibilities for dynamic and complex biological genomic analyses. Combining these technologies may lead to a deeper understanding of heterogeneous polygenic CVDs, better prognostic guidance, and, ultimately, greater personalized medicine. Advances will likely be achieved through increasingly frequent and robust genomic characterization of patients, as well the integration of genomic data with other clinical data, such as cardiac imaging, coronary angiography, and clinical biomarkers. This review discusses the current opportunities and limitations of genomics; provides a brief overview of AI; and identifies the current applications, limitations, and future directions of AI in genomics.

Aortic Stenosis and Mitral Regurgitation are common valvular conditions representing a hidden burden of disease within the population. The aim of this study was to develop and validate deep learning-based screening and diagnostic tools that can help guide clinical decision making.In this multi-center retrospective cohort study, we acquired Transthoracic Echocardiogram reports from five Mount Sinai hospitals within New York City representing a demographically diverse cohort of patients. We developed a Natural Language Processing pipeline to extract ground-truth labels about valvular status and paired these to Electrocardiograms (ECGs). We developed and externally validated deep learning models capable of detecting valvular disease, in addition to considering scenarios of clinical deployment.We use 617,338 ECGs paired to transthoracic echocardiograms from 123,096 patients to develop a deep learning model for detection of Mitral Regurgitation. Area Under Receiver Operating Characteristic curve (AUROC) is 0.88 (95% CI:0.88-0.89) in internal testing, and 0.81 (95% CI:0.80-0.82) in external validation. To develop a model for detection of Aortic Stenosis, we use 617,338 Echo-ECG pairs for 128,628 patients. AUROC is 0.89 (95% CI: 0.88-0.89) in internal testing, going to 0.86 (95% CI: 0.85-0.87) in external validation. The model's performance increases leading up to the time of the diagnostic echo, and it performs well in validation against requirement of Transcatheter Aortic Valve Replacement procedures.Deep learning based tools can increase the amount of information extracted from ubiquitous investigations such as the ECG. Such tools are inexpensive, can help in earlier disease detection, and potentially improve prognosis.The valves of the heart have flaps that open and close when the heart beats to maintain the flow of blood in the correct direction. Valvular disease, such as backflow or narrowing, puts additional strain upon heart muscles which can lead to heart failure. Usually, these conditions are diagnosed by doing an echocardiogram, an ultrasound scan of the heart and nearby blood vessels. The electrocardiogram (ECG) records the electrical signal generated by the heart and can be obtained more easily. We used deep learning neural networks, self-learning computer algorithms which excel at finding patterns within complex data. This enabled us to develop computer software able to diagnose valvular disease from ECGs. Earlier detection of such disease can help in improving overall outcome, while also reducing costs related to treatment.

Radial approaches are classified into traditional radial access (TRA) and more contemporary distal radial access (DRA), with recently published comparative studies reporting inconsistent outcomes. As there have been several recent randomized control trials (RCT), we assessed the totality of evidence in an updated meta-analysis to compare outcomes of DRA and TRA.We searched PubMed, CENTRAL, Web of Science, EMBASE, and Cochrane Database of Systematic Reviews from inception to August 2022 for studies comparing DRA and TRA for coronary angiography. Primary outcomes were the rate of radial artery occlusion (RAO) and access failure. Secondary outcomes included hematomas and puncture site bleeding. The pooled risk ratio (RR) with 95 % confidence interval (95 % CI) was calculated for each outcome.A total of 14,071 patients undergoing coronary angiography from 23 studies, including 5488 patients from 10 RCTs. The mean age of the study population was 59.8 ± 5.9 years with 66.2 % men. Outcomes for a total of 6796 (48.3 %) patients undergoing DRA and 7166 (50.9 %) patients undergoing TRA were compared. DRA was associated with a lower rate of RAO (RR = 0.36, 95CI [0.27, 0.48], I2 = 0 %) but an increased risk of vascular access failure (RR = 2.38, 95CI [1.46, 3.87], I2 = 82.7 %). There was no significant difference in the rate of bleeding or hematoma formation.In an updated metanalysis, DRA is associated with lower rates of RAO but with higher rates of access failure.

This article review covers carotid artery disease, abdominal aortic aneurysm, and atherosclerotic renal artery disease. It overviews each condition's clinical presentation, diagnosis, medical management, and interventional approach. Carotid artery disease is characterized by hemispheric and neuropsychological manifestations, which can help detect this condition. Screening for carotid artery stenosis is recommended in high-risk individuals and can be performed using different methods, with carotid duplex ultrasonography being the preferred option. Carotid endarterectomy and carotid artery stenting are indicated based on specific criteria and patient characteristics. Abdominal aortic aneurysm is often asymptomatic, but abdominal, back, or flank pain may sometimes be present. Ultrasonography is an effective method for screening and monitoring abdominal aortic aneurysm, with high sensitivity and specificity. Smoking cessation is a crucial intervention for preventing further enlargement of small aortic aneurysms. Repair of abdominal aortic aneurysm is recommended based on the aneurysm size, growth rate, and the presence of symptoms. Endovascular repair is preferred when suitable anatomy is present. Atherosclerotic renal artery disease is associated with resistant hypertension, renal failure, and occasionally pulmonary edema. Doppler ultrasonography is a valuable diagnostic tool for detecting it, while the renal resistive index provides additional insights into disease severity and treatment response. Revascularization is not routinely recommended for atherosclerotic renal artery disease, but it may be considered in specific cases, such as renal arterial fibromuscular dysplasia or unexplained congestive heart failure.

Lower extremity peripheral artery disease (PAD) is common among patients with several risk factors, such as elderly, smoking, hypertension, and diabetes mellitus. Notably, PAD is associated with a higher risk of cardiovascular complications. Non-invasive interventions are beneficial to improve morbidity and mortality among patients with PAD. Traditional risk factors like smoking, diabetes mellitus, hypertension, and dyslipidemia play a significant role in the development of PAD. Still, additional factors such as mental health, glycemic control, diet, exercise, obesity management, lipid-lowering therapy, and antiplatelet therapy have emerged as important considerations. Managing these factors can help improve outcomes and reduce complications in PAD patients. Antiplatelet therapy with aspirin or clopidogrel is recommended in PAD patients, with clopidogrel showing more significant benefits in symptomatic PAD individuals. Managing several risk factors is crucial for improving outcomes and reducing complications in patients with PAD. Further research is also needed to explore the potential benefits of novel therapies. Ultimately, a comprehensive approach to PAD management is essential for improving morbidity and mortality among patients with this condition.

The global epidemiological transition of atherosclerotic vascular diseases is witnessing a rapid redistribution of its burden, shifting from high-income to low- and middle-income countries. With a wide clinical spectrum, spanning from intermittent claudication to more complex critical limb threatening ischemia, nonhealing ulcers, gangrene as well as acute limb ischemia, peripheral artery disease is often faced with the challenges of under-diagnosis and under-treatment despite its high prevalence. The management of peripheral arterial disease in patients with multiple comorbidities presents a formidable challenge and remains a pressing global health concern. In this review, we aim to provide an in-depth overview of the pathophysiology of peripheral artery disease and explore evidence-based management strategies encompassing pharmacological, lifestyle, interventional, and surgical approaches. By addressing these challenges, the review contributes to a better understanding of the evolving landscape of peripheral artery disease, offering insights into effective and holistic management strategies.

BackgroundAlthough electrolyte disturbances may affect cardiac action potential, little is known about the association between serum magnesium and corrected QT (QTc) interval as well as clinical outcomes.MethodsA consecutive 8498 patients admitted to the Mayo Clinic Hospital—Rochester cardiac care unit (CCU) from January 1, 2004 through December 31, 2013 with 2 or more documented serum magnesium levels, were studied to test the hypothesis that serum magnesium levels are associated with in-hospital mortality, sudden cardiac death, and QTc interval.ResultsPatients were 67 ± 15 years; 62.2% were male. The primary diagnoses for CCU admissions were acute myocardial infarction (50.7%) and acute decompensated heart failure (42.5%), respectively. Patients with higher magnesium levels were older, more likely male, and had lower glomerular filtration rates. After multivariate analyses adjusted for clinical characteristics including kidney disease and serum potassium, admission serum magnesium levels were not associated with QTc interval or sudden cardiac death. However, the admission magnesium levels ≥2.4 mg/dL were independently associated with an increase in mortality when compared with the reference level (2.0 to <2.2 mg/dL), having an adjusted odds ratio of 1.80 and a 95% confidence interval of 1.25-2.59. The sensitivity analysis examining the association between postadmission magnesium and analysis that excluded patients with kidney failure and those with abnormal serum potassium yielded similar results.ConclusionThis retrospective study unexpectedly observed no association between serum magnesium levels and QTc interval or sudden cardiac death. However, serum magnesium ≥2.4 mg/dL was an independent predictor of increased hospital morality among CCU patients.

Bileaflet mitral valve prolapse (biMVP) is associated with frequent ventricular ectopy (VE) and malignant ventricular arrhythmia. We examined the effect of mitral valve (MV) surgery on VE burden in biMVP patients. We included 32 consecutive patients undergoing MV surgery for mitral regurgitation secondary to biMVP between 1993 and 2012 at Mayo Clinic who had available pre- and post-operative Holter monitoring data. Characteristics of patients with a significant reduction in postoperative VE (group A, defined as >10% reduction in VE burden compared to baseline) were compared with the rest of study patients (group B). In the overall cohort, VE burden was unchanged after the surgery (41 interquartile range [16, 196] pre-surgery vs. 40 interquartile range [5186] beats/hour [bph] post-surgery; P = 0.34). However, in 17 patients (53.1%), VE burden decreased by at least 10% after the surgery. These patients (group A) were younger than the group B (59 ± 15 vs. 68 ± 7 years; P = 0.04). Other characteristics including pre- and postoperative left ventricular function and size were similar in both groups. Age <60 years was associated with a reduction in postoperative VE (odds ratio 5.8; 95% confidence interval, 1.1–44.7; P = 0.03). Furthermore, there was a graded relationship between age and odds of VE reduction with surgery (odds ratio 1.9; 95% confidence interval 1.04–4.3 per 10-year; P = 0.04). MV surgery does not uniformly reduce VE burden in patients with biMVP. However, those patients who do have a reduction in VE burden are younger, perhaps suggesting that early surgical intervention could modify the underlying electrophysiologic substrate.

We examined risks for first hospitalization and the rate, risk factors, costs, and 1‐year outcome of 30‐day readmission among patients admitted for complications of cirrhosis. Data were retrospectively analyzed for adult patients with cirrhosis residing in Minnesota, Iowa, or Wisconsin and admitted from 2010 through 2013 at both campuses of the Mayo Clinic Hospital in Rochester, MN. Readmission was captured at the two hospitals as well as at community hospitals in the tristate area within the Mayo Clinic Health System. The incidence of hospitalization for complications of cirrhosis was 100/100,000 population, with increasing age and male sex being the strongest risks for hospitalization. For the 2,048 hospitalized study patients, the overall 30‐day readmission rate was 32%; 498 (24.3%) patients were readmitted to Mayo Clinic hospitals and 157 (7.7%) to community hospitals, mainly for complications of portal hypertension (52%) and infections (30%). Readmission could not be predicted accurately. There were 146 deaths during readmission and an additional 105 deaths up to 1 year of follow‐up (50.4% total mortality). Annual postindex hospitalization costs for those with a 30‐day readmission were substantially higher ($73,252) than those readmitted beyond 30 days ($62,053) or those not readmitted ($5,719). At 1‐year follow‐up, only 20.4% of patients readmitted within 30 days were at home. In conclusion, patients with cirrhosis have high rates of hospitalization, especially among men over 65 years, and of unscheduled 30‐day readmission. Readmission cannot be accurately predicted. Postindex hospitalization costs are high; nationally, the annual costs are estimated to be more than $4.45 billion. Only 20% of patients readmitted within 30 days are home at 1 year. ( Hepatology Communications 2018;2:188–198)

<h2>Abstract</h2><h3>Background</h3> Women are undertreated and have worse clinical outcomes than men after acute myocardial infarction. It remains uncertain whether the sex disparities in treatments and outcomes persist in the contemporary era and whether they affect all age groups equally. <h3>Methods</h3> Using the National Inpatient Sample (NIS) registry, we evaluated 1,260,200 hospitalizations for ST-elevation myocardial infarction (STEMI) between 2010 and 2016, of which 32% were for women. The age-stratified sex differences in care measures and mortality were examined. Stepwise multivariable adjustment models, including baseline comorbidities, hospital characteristics, and reperfusion and revascularization therapies, were used to compare measures and outcomes between women and men across different age subgroups. <h3>Results</h3> Overall, women with STEMI were older than men and had more comorbidities. Women were less likely to receive fibrinolytic therapy, percutaneous coronary intervention (PCI), and coronary artery bypass surgery across all age subgroups. Women with STEMI overall experienced higher unadjusted in-hospital mortality (11.1% vs 6.8%; adjusted odds ratio [OR] = 1.039, 95% confidence interval [CI]: 1.003-1.077), which persisted after multivariable adjustments. However, when stratified by age, the difference in mortality became non-significant in most age groups after stepwise multivariable adjustment, except among the youngest patients 19-49 years of age with STEMI (women vs men: 3.9% vs 2.6%; adjusted odds ratio = 1.259, 95% confidence interval: 1.083-1.464). <h3>Conclusions</h3> Women with STEMI were less likely to receive reperfusion and revascularization therapies and had higher in-hospital mortality and complications compared with men. Younger women with STEMI (19-49 years of age) experienced higher in-hospital mortality that persisted after multivariable adjustment.

Studies evaluating fish consumption and cardiovascular disease events have shown inconsistent results. We performed a systematic review of peer-reviewed publications from an extensive query of Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from database inception to September 2020 for observational studies that reported the association between fish consumption and cardiovascular disease events. We identified and reviewed 24 studies related to fish consumption and the effect on cardiovascular outcomes. The study population included a total of 714,526 individuals and multiple cohorts from several countries. We found that nonfried fish consumption is probably associated with a reduced risk of overall cardiovascular disease events and myocardial infarction risk. In contrast, fried fish consumption is probably associated with an increased risk of overall cardiovascular disease events and myocardial infarction risk. No studies to date have shown any significant association between fish consumption and stroke. Our analysis suggests that fish consumption may reduce cardiovascular disease events, but fried fish consumption was associated with an increased risk of cardiovascular events.

Studies evaluating alcohol consumption and cardiovascular diseases have shown inconsistent results.We performed a systematic review of peer-reviewed publications from an extensive query of Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from database inception to March 2022 for all studies that reported the association between alcohol consumption in terms of quantity (daily or weekly amounts) and type of beverage (wine, beer or spirit) and cardiovascular disease events.The study population included a total of 1,579,435 individuals based on 56 cohorts from several countries. We found that moderate wine consumption defined as 1-4 drinks per week was associated with a reduction in risk for cardiovascular mortality when compared with beer or spirits. However, higher risk for cardiovascular disease mortality was typically seen with heavier daily or weekly alcohol consumption across all types of beverages.It is possible that the observational studies may overestimate the benefits of alcohol for cardiovascular disease outcomes. Although moderate wine consumption is probably associated with low cardiovascular disease events, there are many confounding factors, in particular, lifestyle, genetic, and socioeconomic associations with wine drinking, which likely explain much of the association with wine and reduced cardiovascular disease events. Further prospective study of alcohol and all-cause mortality, including cancer, is needed.

Cardiorenal syndrome (CRS) is an increasingly recognized diagnostic entity associated with high morbidity and mortality among acutely ill heart failure (HF) patients with acute and/ or chronic kidney diseases (CKD). While traditionally viewed as a state of decline in glomerular filtration rate (GFR) due to decreased renal perfusion, mainly due to therapeutic interventions to relieve congestive in HF, recent insights into the underlying pathophysiologic mechanisms of CRS led to a broader definition and further classification of CRS into 5 distinct types. In this comprehensive review, we discuss the classification of CRS, highlighting the underlying common pathogenetic pathways of heart failure and kidney injury, including increased congestion, neurohormonal dysregulation, oxidative stress as well as inflammation, and cytokine storm that are particularly evident in COVID-19 patients with multiorgan failure and also in those with other disorders including sepsis, systemic lupus erythematosus and amyloidosis. In this review we also present the recent advances in the diagnostic strategies of CRS including cardiac and renal biomarkers as well as advanced cardiac and renal imaging techniques that are available to aid in the diagnosis as well as in the prognostication of this disorder. Finally, we discuss the various therapeutic options available to-date, including fluid optimization, hemofiltration, renal replacement therapy as well as the role of SGLT2 inhibitors in light of recent data from RCTs. It is important to note that, CRS population are either excluded or underrepresented, at best, in major RCTs and therefore, therapeutic recommendations are largely extrapolated from HF and CKD clinical trials.

With expanding commercial space programs, uncertainty remains about the cardiovascular effects of space environmental exposures including microgravity, confinement, isolation, space radiation, and altered bacterial virulence. Current limited data suggests additional health threats compared to Earth.We systematically reviewed PubMed, CENTRAL, Web of Science, EMBASE and Cochrane databases for prospective studies on spaceflight and cardiovascular outcomes. Search terms combined cardiovascular disease topics with spaceflight concepts. No date or language restrictions were imposed.35 studies representing 2696 space travelers met inclusion criteria. Studies were grouped into spaceflight associations with: atherosclerosis, mortality, cardiac function, orthostatic intolerance, and arrhythmias. Atherosclerosis evidence was limited, with animal studies linking space radiation to endothelial damage, oxidative stress, and inflammation. However, human data showed no significantly increased atherosclerotic disease in astronauts. Mortality studies demonstrated lower cardiovascular mortality in astronauts compared to the general population however there was conflicting data. Cardiac function studies revealed physiologic ventricular atrophy, increased arterial stiffness, and altered blood flow distribution attributed to microgravity exposure. Effects appeared transient and reversible post-flight. Orthostatic intolerance studies found astronauts experienced altered heart rate variability, baroreflex response, and blood pressure changes post-flight. Arrhythmia studies showed increased ventricular ectopy during spaceflight, but limited data on long term flights.Environmental space hazards impact the cardiovascular system through multiple mechanisms. Microgravity causes cardiac atrophy and orthostatic intolerance while space radiation may potentially accelerate atherosclerosis. Further research is needed, especially regarding long-term spaceflights.

Stress cardiomyopathy was noted to occur at a higher incidence during coronavirus disease of 2019 (COVID-19) pandemic. This database analysis has been done to compare the in-hospital outcomes in patients with stress cardiomyopathy and concurrent COVID-19 infection with those without COVID-19 infection. The National Inpatient Sample database for the year 2020 was queried to identify all admissions diagnosed with stress cardiomyopathy. These patients were then stratified based on whether they had concomitant COVID-19 infection or not. A 1:1 propensity score matching was performed. Multivariate logistic regression analysis was done to identify predictors of mortality. We identified 41,290 hospitalizations for stress cardiomyopathy, including 1665 patients with concurrent diagnosis of COVID-19. The female preponderance was significantly lower in patients with stress cardiomyopathy and COVID-19. Patients with concomitant COVID-19 were more likely to be African American, diabetic and have chronic kidney disease. After propensity matching, the incidence of complications, including acute kidney injury (AKI), AKI requiring dialysis, coagulopathy, sepsis, cardiogenic shock, cases with prolonged intubation of >24 h, requirement of vasopressor and inpatient mortality, were noted to be significantly higher in patients with COVID-19. Concomitant COVID-19 infection was independently associated with worse outcomes and increased mortality in patients hospitalized with stress cardiomyopathy.

The main objective of this systematic review and meta-analysis was to investigate the association between white rice consumption and risk of metabolic and cardiovascular outcomes.We conducted a comprehensive search of Medline, Embase, Scopus, and the Cochrane Central Register of Controlled Trials from database inception through March 2016. Original studies that reported associations between white rice consumption and cardiovascular outcomes regardless of study design were selected. We extracted study characteristics and outcome data. Conflicts were resolved through consensus. Using the DerSimonian and Laird random effects models, we calculated pooled relative risks with 95% CI.Our search identified 721 citations. 18 studies were included with a total of 1 777 059 individuals: 14 348 had type 2 diabetes mellitus (T2DM); 5612 had metabolic syndrome (MetS); 10 839 had coronary heart disease (CHD); and 11 698 had stroke. Compared with the lowest category, the highest category of white rice consumption was only associated with 30% higher risk of MetS (pooled OR 1.30, 95% CI 1.03 to 1.65; p<0.001; I²=65.5%).Higher white rice consumption has not been shown to be associated with increased risk of CHD, stroke and T2DM. However, white rice consumption may be associated with increased risk of MetS in certain populations.

Though infrequent, spontaneous coronary artery dissection (SCAD) is increasingly recognized as an important cause of acute coronary syndrome (ACS), particularly in young healthy women. However, the population-based incidence of SCAD is unknown. We evaluated the incidence, patient characteristics, clinical characteristics, and mortality of SCAD-related hospitalizations using data from a national population-based cohort study from January 1, 2004, to September 30, 2015. In 13,573,200 patients who presented with an acute coronary syndrome, 66,360 (0.49%) of patients were diagnosed with SCAD. The mean age was 63.1 ± 13.2 years and 44.2% were women. In-hospital mortality of SCAD patients was 4.2%: 5.03% in females and 3.55% in males (p < 0.001). In conclusion, SCAD is an uncommon diagnosis that should be considered in males and older patients in addition to females presenting with ACS. Most SCAD patients today are managed medically. In-hospital mortality is comparable to that of other patients who present with ACS. Though infrequent, spontaneous coronary artery dissection (SCAD) is increasingly recognized as an important cause of acute coronary syndrome (ACS), particularly in young healthy women. However, the population-based incidence of SCAD is unknown. We evaluated the incidence, patient characteristics, clinical characteristics, and mortality of SCAD-related hospitalizations using data from a national population-based cohort study from January 1, 2004, to September 30, 2015. In 13,573,200 patients who presented with an acute coronary syndrome, 66,360 (0.49%) of patients were diagnosed with SCAD. The mean age was 63.1 ± 13.2 years and 44.2% were women. In-hospital mortality of SCAD patients was 4.2%: 5.03% in females and 3.55% in males (p < 0.001). In conclusion, SCAD is an uncommon diagnosis that should be considered in males and older patients in addition to females presenting with ACS. Most SCAD patients today are managed medically. In-hospital mortality is comparable to that of other patients who present with ACS.

The field of human space travel is in the midst of a dramatic revolution. Upcoming missions are looking to push the boundaries of space travel, with plans to travel for longer distances and durations than ever before. Both the National Aeronautics and Space Administration (NASA) and several commercial space companies (e.g., Blue Origin, SpaceX, Virgin Galactic) have already started the process of preparing for long-distance, long-duration space exploration and currently plan to explore inner solar planets (e.g., Mars) by the 2030s. With the emergence of space tourism, space travel has materialized as a potential new, exciting frontier of business, hospitality, medicine, and technology in the coming years. However, current evidence regarding human health in space is very limited, particularly pertaining to short-term and long-term space travel. This review synthesizes developments across the continuum of space health including prior studies and unpublished data from NASA related to each individual organ system, and medical screening prior to space travel. We categorized the extraterrestrial environment into exogenous (e.g., space radiation and microgravity) and endogenous processes (e.g., alteration of humans' natural circadian rhythm and mental health due to confinement, isolation, immobilization, and lack of social interaction) and their various effects on human health. The aim of this review is to explore the potential health challenges associated with space travel and how they may be overcome in order to enable new paradigms for space health, as well as the use of emerging Artificial Intelligence based (AI) technology to propel future space health research.

Genetic polymorphisms or variations, randomly distributed in a population, may cause drug-gene response variations. Investigation into these polymorphisms may identify novel mechanisms contributing to a specific disease process. Such investigation necessitates the use of Mendelian randomization, an analytical method that uses genetic variants as instrumental variables for modifiable risk factors that affect population health.1 In the past decade, advances in our understanding of genetic polymorphisms have enabled the identification of genetic variants in candidate genes that impact low-density lipoprotein cholesterol (LDL-C) regulating pathways and cardiovascular disease (CVD) outcomes. A specific candidate gene of interest is that of the LDL receptor degrading protein, PCSK9. In fact, loss-of-function genetic variants for the PCSK9 gene are what first highlighted this pathway as a candidate for pharmacologic inhibition. PCSK9 inhibitors (PCSK9i) are a class of cholesterol-lowering medications that provide significant reductions in LDL by inhibiting the degradation of LDL receptors (LDLR). These inhibitors have also been found to reduce production and enhance clearance of lipoprotein A (Lp[a]), an LDL-like particle currently under study as a separate risk factor for atherosclerotic CVD. Here, we discuss the promise of personalized medicine in developing a more efficacious and individualized pharmacogenomics-based approach for the use of PCSK9i that considers genetic variation and targets different patient populations. This review explores the pharmacogenomics of PCSK9i in the context of PCSK9 allele variants related to drug-metabolizing enzymes and responses since more studies are demonstrating that some patients are hyporesponsive or non-responsive to PCSK9i.2 In summary, the pharmacogenomics of PCSK9 are a promising therapeutic target and genetic information from prospective randomized clinical trials is warranted to gain a full understanding of the efficacy and cost-effectiveness of such allele and/or gene-guided PCSK9i therapy.

The effect of psychological health on cardiovascular disease is an underappreciated yet important area of study. Understanding the relationship between these two entities may allow for more comprehensive care of those with cardiovascular disease. The primary objective of this meta-analysis is to evaluate the relationship between optimism and risk of developing adverse events such as all-cause mortality or fatal and non-fatal cardiovascular disease in community-based populations.A systematic search of electronic databases was conducted from inception through November 2021 for prospective studies evaluating optimism and adverse outcomes. Two reviewers independently selected prospective cohort studies that evaluated optimism and either all-cause mortality or cardiovascular disease and reported hazard ratios of these outcomes between optimistic and non-optimistic groups. Studies that reported odds ratio or other risk assessments were excluded. Pooled hazard ratios were calculated in random-effects meta-analyses.Pooled analysis of six studies (n = 181,709) showed a pooled hazard ratio of 0.87 (95% confidence interval [CI], 0.82-0.92) for all-cause mortality among those with more optimistic mindset. Analysis of seven studies (n = 201,210) showed a pooled hazard ratio of 0.59 (95% CI, 0.37-0.93) for cardiovascular disease and pooled hazard ratio of 0.57 (95% CI, 0.07-4.56) for stroke.In this pooled meta-analysis, optimism was associated with a reduced risk of all-cause mortality and of cardiovascular disease. These results suggest an important relationship between psychological health and cardiovascular disease that may serve as an area for intervention by clinicians.

Sugar-sweetened and artificially sweetened beverages are routinely consumed worldwide. Given their popularity, there has been much debate about the effect that these beverages have on cardiovascular health. We sought to determine the exact relationship between sugar-sweetened and artificially sweetened beverages consumption on cardiovascular health.All studies that reported an association between sugar-sweetened/artificially sweetened beverages consumption and cardiovascular health were extracted from database inception to September 2022 using keywords from several databases. We used the DerSimonian & Laird random-effects method for the analysis.Of the total 16 prospective studies, 1,405,375 individuals were followed for a median follow-up of 14.8 years. Compared with low sugar-sweetened and artificially sweetened beverage consumption, a higher consumption of sugar-sweetened and artificially sweetened beverages was associated with greater cardiovascular outcomes (hazard ratio [HR] of 1.27, 95% confidence interval [CI] of 1.16-1.40 and risk ratios of 1.16, 95% CI of 1.02-1.33). Similarly, compared with low artificially sweetened beverages consumption, a higher consumption of artificially sweetened beverages was associated with greater cardiovascular outcomes (HR of 1.32, 95% CI of 1.12-1.57). Likewise, compared with low sugar-sweetened beverages consumption, a higher consumption of sugar-sweetened beverages was associated with greater cardiovascular outcomes (HR of 1.21, 95% CI of 1.07-1.37 and risk ratios of 1.22, 95% CI of 1.09-1.35).Increasing consumption of sugar-sweetened and artificially sweetened beverages may be correlated with an increased risk of developing cardiovascular/vascular complications and mortality, albeit without causality of cardiovascular/vascular morbidity.

Primary care has the potential to be transformed by artificial intelligence (AI) and, in particular, machine learning (ML). This review summarizes the potential of ML and its subsets in influencing two domains of primary care: pre-operative care and screening. ML can be utilized in preoperative treatment to forecast postoperative results and assist physicians in selecting surgical interventions. Clinicians can modify their strategy to reduce risk and enhance outcomes using ML algorithms to examine patient data and discover factors that increase the risk of worsened health outcomes. ML can also enhance the precision and effectiveness of screening tests. Healthcare professionals can identify diseases at an early and curable stage by using ML models to examine medical pictures, diagnostic modalities, and spot patterns that may suggest disease or anomalies. Before the onset of symptoms, ML can be used to identify people at an increased risk of developing specific disorders or diseases. ML algorithms can assess patient data such as medical history, genetics, and lifestyle factors to identify those at higher risk. This enables targeted interventions such as lifestyle adjustments or early screening. In general, using ML in primary care offers the potential to enhance patient outcomes, reduce healthcare costs, and boost productivity.

Abstract Purpose Statins are first-line agents to reduce low-density lipoprotein cholesterol (LDL-C) and cardiovascular risk, however, they are insufficient and/or intolerable in many patients. To that end, we conducted a meta-analysis of Bempedoic Acid (BA), a novel LDL-C lowering agent. Methods We retrieved randomized clinical trials (RCTs) of BA by searching Pubmed, the Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov. We used the Mantel-Haenszel method to pool estimates. The I 2 measure was used to quantify heterogeneity. Treatment effects are provided as relative risks (RR), absolute risk differences (ARD), and number needed to treat/harm (NNTB/H). Analyses were conducted using R, version 4.1.2. Results 11 trials enrolling 18,496 patients were included. Compared to placebo, BA reduced the risk of major adverse cardiovascular events (RR: 0.87; 95% CI: 0.80 to 0.95; ARD: -1.63%; NNT: 62), myocardial infarction (RR: 0.76; 95% CI: 0.66 to 0.89; ARD: -1.03%; NNT: 98), unstable angina hospitalization (RR: 0.70; 95%: CI: 0.55 to 0.89; ARD: -0.57%; NNT: 177), revascularization (RR: 0.81; 95% CI: 0.72 to 0.91; ARD: -1.31%; NNT: 77), and myalgia (RR: 0.85; 95% CI: 0.75 to 0.95; ARD: -0.99%; NNT: 102). BA significantly increased the risk of gout (RR: 1.56; 95% CI: 1.27 to 1.91; ARD: 0.99%; NNH: 101), renal impairment (RR: 1.35; 95% CI: 1.22 to 1.49; ARD: 2.54%; NNH: 40), and cholelithiasis (RR: 1.87; 95% CI: 1.43 to 2.44; ARD: 1.01%; NNH: 100). Conclusion BA effectively reduces the risk of cardiovascular events and myalgia but increases the risk of gout, cholelithiasis, and renal impairment.

In recent years, there has been a significant surge in discussions surrounding artificial intelligence (AI), along with a corresponding increase in its practical applications in various facets of everyday life, including the medical industry. Notably, even in the highly specialized realm of neurosurgery, AI has been utilized for differential diagnosis, pre-operative evaluation, and improving surgical precision. Many of these applications have begun to mitigate risks of intraoperative and postoperative complications and post-operative care. This article aims to present an overview of the principal published papers on the significant themes of tumor, spine, epilepsy, and vascular issues, wherein AI has been applied to assess its potential applications within neurosurgery. The method involved identifying high-cited seminal papers using PubMed and Google Scholar, conducting a comprehensive review of various study types, and summarizing machine learning applications to enhance understanding among clinicians for future utilization. Recent studies demonstrate that machine learning (ML) holds significant potential in neuro-oncological care, spine surgery, epilepsy management, and other neurosurgical applications. ML techniques have proven effective in tumor identification, surgical outcomes prediction, seizure outcome prediction, aneurysm prediction, and more, highlighting its broad impact and potential in improving patient management and outcomes in neurosurgery. This review will encompass the current state of research, as well as predictions for the future of AI within neurosurgery.

Cardiogenic shock is a critical condition of low cardiac output resulting in insufficient systemic perfusion and end-organ dysfunction. Though significant advances have been achieved in reperfusion therapy and mechanical circulatory support, cardiogenic shock continues to be a life-threatening condition associated with a high rate of complications and excessively high patient mortality, reported to be between 35% and 50%. Extracorporeal membrane oxygenation can provide full cardiopulmonary support, has been increasingly used in the last two decades, and can be used to restore systemic end-organ hypoperfusion. However, a paucity of randomized controlled trials in combination with high complication and mortality rates suggest the need for more research to better define its efficacy, safety, and optimal patient selection. In this review, we provide an updated review on VA-ECMO, with an emphasis on its application in cardiogenic shock, including indications and contraindications, expected hemodynamic and echocardiographic findings, recommendations for weaning, complications, and outcomes. Furthermore, specific emphasis will be devoted to the two published randomized controlled trials recently presented in this setting.

Acute myocardial infarction is an important cause of death worldwide. While it often affects patients of older age, acute myocardial infarction is garnering more attention as a significant cause of morbidity and mortality among young patients (<45 years of age). More specifically, there is a focus on recognizing the unique etiologies for myocardial infarction in these younger patients as nonatherosclerotic etiologies occur more frequently in this population. As such, there is a potential for delayed and inaccurate diagnoses and treatments that can carry serious clinical implications. The understanding of acute myocardial infarction manifestations in young patients is evolving, but there remains a significant need for better strategies to rapidly diagnose, risk stratify, and manage such patients. This comprehensive review explores the various etiologies for acute myocardial infarction in young adults and outlines the approach to efficient diagnosis and management for these unique patient phenotypes.

•We describe a methodology to capture statin-associated side effects (SASEs) entered in the electronic medical record by clinicians. •The methodology accurately identified atherosclerotic cardiovascular disease patients with SASEs (positive predictive value 99%). •Two-thirds of SASEs were related to muscle symptoms. •Patients with SASEs had lower statin use and higher low-density lipoprotein cholesterol and non–high-density lipoprotein cholesterol levels. •This automated strategy to identify SASEs is scalable at health care system level. Background Accurate identification of patients with statin-associated side effects (SASEs) is critical for health care systems to institute strategies to improve guideline-concordant statin use. Objective The objective of this study was to determine whether adverse drug reaction (ADR) entry by clinicians in the electronic medical record can accurately identify SASEs. Methods We identified 1,248,214 atherosclerotic cardiovascular disease (ASCVD) patients seeking care in the Department of Veterans Affairs. Using an ADR data repository, we identified SASEs in 15 major symptom categories. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were assessed using a chart review of 256 ASCVD patients with identified SASEs, who were not on high-intensity statin therapy. Results We identified 171,189 patients (13.71%) with documented SASEs over a 15-year period (9.9%, 2.7%, and 1.1% to 1, 2, or >2 statins, respectively). Statin use, high-intensity statin use, low-density lipoprotein cholesterol, and non–high-density lipoprotein cholesterol levels were 72%, 28.1%, 99 mg/dL, and 129 mg/dL among those with vs 81%, 31.1%, 84 mg/dL, and 111 mg/dL among those without SASEs. Progressively lower statin and high-intensity statin use, and higher low-density lipoprotein cholesterol and non–high-density lipoprotein cholesterol levels were noted among those with SASEs to 1, 2, or >2 statins. Two-thirds of SASEs were related to muscle symptoms. Sensitivity, specificity, PPV, NPV compared with manual chart review were 63.4%, 100%, 100%, and 85.3%, respectively. Conclusion A strategy of using ADR entry in the electronic medical record is feasible to identify SASEs with modest sensitivity and NPV but high specificity and PPV. Health care systems can use this strategy to identify ASCVD patients with SASEs and operationalize efforts to improve guideline-concordant lipid-lowering therapy use in such patients. The sensitivity of this approach can be further enhanced by the use of unstructured text data. Accurate identification of patients with statin-associated side effects (SASEs) is critical for health care systems to institute strategies to improve guideline-concordant statin use. The objective of this study was to determine whether adverse drug reaction (ADR) entry by clinicians in the electronic medical record can accurately identify SASEs. We identified 1,248,214 atherosclerotic cardiovascular disease (ASCVD) patients seeking care in the Department of Veterans Affairs. Using an ADR data repository, we identified SASEs in 15 major symptom categories. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were assessed using a chart review of 256 ASCVD patients with identified SASEs, who were not on high-intensity statin therapy. We identified 171,189 patients (13.71%) with documented SASEs over a 15-year period (9.9%, 2.7%, and 1.1% to 1, 2, or >2 statins, respectively). Statin use, high-intensity statin use, low-density lipoprotein cholesterol, and non–high-density lipoprotein cholesterol levels were 72%, 28.1%, 99 mg/dL, and 129 mg/dL among those with vs 81%, 31.1%, 84 mg/dL, and 111 mg/dL among those without SASEs. Progressively lower statin and high-intensity statin use, and higher low-density lipoprotein cholesterol and non–high-density lipoprotein cholesterol levels were noted among those with SASEs to 1, 2, or >2 statins. Two-thirds of SASEs were related to muscle symptoms. Sensitivity, specificity, PPV, NPV compared with manual chart review were 63.4%, 100%, 100%, and 85.3%, respectively. A strategy of using ADR entry in the electronic medical record is feasible to identify SASEs with modest sensitivity and NPV but high specificity and PPV. Health care systems can use this strategy to identify ASCVD patients with SASEs and operationalize efforts to improve guideline-concordant lipid-lowering therapy use in such patients. The sensitivity of this approach can be further enhanced by the use of unstructured text data.

The 2013 American Heart Association Scientific Statement on pet ownership and cardiovascular risk suggested that dog ownership is probably associated with decreased cardiovascular risk. Several studies have been shown that pet ownership, particularly of dogs, is associated with increased physical activity levels, social support, and improved outcomes after a major cardiovascular event. We hypothesized that pet ownership is associated with a lower risk of cardiovascular disease in the US general population. Using the National Health and Nutrition Examination Survey, we identified all patients with heart failure, coronary artery disease, systemic hypertension (SH), diabetes mellitus, and stroke between 1999 and 2016. Multivariable analyses were performed to adjust for demographic factors such as age, gender, marital status, education, co-morbidities, cigarette smoking, family income, working hours, sleeping duration, depression, and lipid profiles. Of 42,038 National Health and Nutrition Examination Survey participants, 10,905 (31%) were inquired about pet ownership. Pet owners were older, less likely to be women or widowed, and more likely to be white, more educated, tobacco users, and work more than 35 hours per week than non-owners (all p values <0.05). Pet owners had higher hemoglobin, lower low-density lipoprotein cholesterol, and a lower prevalence of DM, SH, and stroke (all p values <0.05). After adjusting for potential confounders, pet ownership (either cat or dog ownership) was independently associated with a lower prevalence of SH (odds ratio 0.67; 95% confidence interval 0.49 to 0.89; p = 0.01), but not heart failure, coronary artery disease, DM, or stroke, compared with non-owners. In conclusions, using a large national database, we found that pet ownership is associated with a decreased prevalence of SH. Further longitudinal studies are needed to draw a conclusion on the protective effect of pet ownership in patients with cardiovascular disease.

<h2>Abstract</h2><h3>Background</h3> Although the association between autoimmune rheumatic diseases and atherosclerotic cardiovascular disease is well-known, there is a lack of data regarding the role of such disorders in patients with premature and extremely premature atherosclerotic cardiovascular disease. <h3>Methods</h3> The Veterans With Premature Atherosclerosis (VITAL) registry, including patients with premature (males <55 years, females <65 years) and extremely premature atherosclerotic cardiovascular disease (<40 years), was created from the 2014-2015 nationwide Veterans Affairs (VA) health care system database. We assessed age at the time of first cardiovascular event to compare patients with premature (n = 135,703) and those with extremely premature atherosclerotic cardiovascular disease (n = 7716) with age-matched patients without atherosclerotic cardiovascular disease (n_young = 1,153,535, n_{extremely young} = 441,836). We assessed whether systemic lupus erythematosus, rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis were independently associated with premature and extremely premature atherosclerotic cardiovascular disease. <h3>Results</h3> Patients with premature and extremely premature atherosclerotic cardiovascular disease had a higher prevalence of all rheumatic diseases as compared with age-matched patients without atherosclerotic cardiovascular disease. In fully adjusted models, systemic lupus erythematosus (odds ratio [OR]: 1.69, 95% confidence interval [CI]: 1.56-1.83) and rheumatoid arthritis (OR: 1.72, 95% CI: 1.63-1.81) were associated with increased odds of premature atherosclerotic cardiovascular disease. Patients with systemic lupus erythematosus (OR: 3.06, 95% CI: 2.38-3.93) and rheumatoid arthritis (OR: 2.39, 95% CI: 1.85-3.08) also had a higher likelihood of extremely premature atherosclerotic cardiovascular disease. <h3>Conclusion</h3> Patients with systemic lupus erythematosus and rheumatoid arthritis carry higher odds of both premature and extremely premature atherosclerotic cardiovascular disease. Future studies are needed to understand the rheumatic disease-specific factors behind the development and progression of clinical atherosclerotic cardiovascular disease in these young patients.

Background Recurrent spontaneous coronary artery dissection (SCAD) is believed to be infrequent. Predictors of recurrent SCAD are poorly characterized. Methods We evaluated the incidence, clinical characteristics, and predictors of recurrent SCAD using data from the Nationwide Readmissions Database from January 1, 2010, to December 30, 2016. Results Among 1836 SCAD patients admitted with the primary diagnosis of SCAD (61.9% female, mean age 56.1 ± 14.5, 72.9% <65 years of age), 495 patients (26.9%) had recurrent SCAD within 1 year (74.0% female, 74% <65 years of age). Multivariable analysis showed that female sex (OR 2.09; 95% CI 1.49–2.95; p < 0.001) was an independent predictor of recurrent SCAD within 1 year. Conclusions Recurrent SCAD is frequent and should be considered in younger females with a history of SCAD. Further research is needed to investigate the mechanistic links between female sex and recurrent SCAD.

HomeJournal of the American Heart AssociationVol. 10, No. 13Revascularization in Patients With Spontaneous Coronary Artery Dissection: Where Are We Now? Open AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toOpen AccessReview ArticlePDF/EPUBRevascularization in Patients With Spontaneous Coronary Artery Dissection: Where Are We Now? Chayakrit Krittanawong, MD, Rajiv Gulati, MD, PhD, Daniel Eitzman, and MD, and Hani JneidMD Chayakrit KrittanawongChayakrit Krittanawong * Correspondence to: Chayakrit Krittanawong, MD, Section of Cardiology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030. E‐mail: E-mail Address: [email protected] https://orcid.org/0000-0001-7953-335X Section of Cardiology, , Baylor College of Medicine and the Michael E. DeBakey Veterans Affairs Medical Center, , Houston, , TX Search for more papers by this author , Rajiv GulatiRajiv Gulati https://orcid.org/0000-0002-2713-0433 Department of Cardiovascular Medicine, , Mayo Clinic, , Rochester, , MN Search for more papers by this author , Daniel EitzmanDaniel Eitzman https://orcid.org/0000-0002-6392-4871 Department of Internal Medicine, , Cardiovascular Research Center, , University of Michigan, , Ann Arbor, , MI Search for more papers by this author , and Hani JneidHani Jneid https://orcid.org/0000-0002-8754-358X Section of Cardiology, , Baylor College of Medicine and the Michael E. DeBakey Veterans Affairs Medical Center, , Houston, , TX Search for more papers by this author Originally published30 Jun 2021https://doi.org/10.1161/JAHA.120.018551Journal of the American Heart Association. 2021;10:e018551Spontaneous coronary artery dissection (SCAD) is a heterogeneous condition that often presents as an acute coronary syndrome in young patients with a paucity of cardiovascular risk factors. In most registries, >90% of patients with SCAD are women.1 SCAD is primarily a non‐atherosclerotic, non‐calcified, non‐iatrogenic dissection of the coronary artery resulting from either an intramural hematoma (IMH) alone, an intimal tear alone, or both an IMH and an intimal tear. Recent studies suggested that an IMH usually precedes the occurrence of an intimal tear.2, 3 Although underlying mechanisms remain unclear, fibromuscular dysplasia, pregnancy, as well as certain autoimmune and inflammatory disorders have been reported as possible predisposing factors in patients with SCAD.1 To date, there are no randomized clinical trials comparing revascularization versus conservative management for SCAD; thus, SCAD management is primarily based on observational data and expert opinion1, 4 (Table 1).5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22Table 1. Registries in Patients With SCAD Comparing Conservative Management Versus RevascularizationAuthorYNo.Age, yWomen (%)Follow‐UpSTEMI (%)NSTEMI (%)ACS (%)Mortality %Medically Managed (%)Revascularization (%)Daoulah et al (G‐SCAD Registry)520208344 [37–55]5118.8 mo (9.06–40.1)49.446.91001.239.860.2García‐Guimaraes et al6202031853 [47–60]884 y3953941.37822Inoue et al720201952.1±6.1100960 d (686–1504)57.82110006337Liu et al8201911857±101443 mo23.723.774.66.87228Lobo et al920195349953 y10001001.93070Abreu et al10201827568220 mo3751.98905545Cade et al11 (P‐SCAD)20171333.8±3.78514 mo46469275446Saw et al12201732752.5913.1 y25.774.3100083.218.7Rogowski et al1320176453944.5 y3069100N/A8812Nakashima et al14201663469434 mo8713100N/A4555McGrath‐Cadell et al15201640459516 mo3065100N/A6733Godinho et al1620161751±95952 mo594110007723Roura et al1720163447954 mo55N/AN/AN/A7723Lettieri et al182015134528272 mo40.349.2932.25941Saw et al19201416852936.9 y267410008020Tweet et al20201418944932.3 y37N/AN/A0.55050Buja et al2120133851.4±11.684.217 mo50297904852Mortensen et al2220092248.7±8.9783.6±2.9 y72N/A100N/A3169John Wiley & Sons, LtdACS indicates acute coronary syndrome; NSTEMI, non–ST‐segment–elevation myocardial infarction; SCAD, spontaneous coronary artery dissection; and STEMI, ST‐segment–elevation myocardial infarction.A retrospective analysis from the Mayo Clinic showed that in patients presenting with SCAD and low‐risk features (clinically stable with TIMI [Thrombolysis in Myocardial Infarction] flow 2–3), both conservative management and revascularization were associated with low mortality (1 of 94 conservative versus 1 of 95 revascularization).20 However, an earlier systematic review inclusive of 440 patients from a total of 381 reports identified in a Medline database search between 1931 and 2008 demonstrated that 21% of conservatively treated patients with SCAD required subsequent revascularization because of early SCAD progression and recurrent ischemia.23 A recent study (n=750 patients) showed that 8.8% of conservatively treated patients with SCAD had major adverse cardiac events within 30 days of initial presentation.24 Another recent study showed that SCAD‐related ST‐segment–elevation myocardial infarction (STEMI) had a higher frequency of left main or left anterior descending culprit lesions (13% versus 1%; P=0.003), and cardiogenic shock (19% versus 9%; P=0.026) compared with STEMI attributable to atherosclerotic plaque disruption.9 We herein summarize the contemporary evidence for revascularization after SCAD and review the indications, techniques, and factors influencing its outcomes.Which Patients With SCAD Should Undergo Revascularization?The decision to revascularize patients with SCAD is challenging, given the associated complications and technical difficulties. An assessment of the clinical presentation and angiographic features is critical when determining whether, when, and how to revascularize patients with SCAD. Invasive coronary angiography is the diagnostic modality of choice for SCAD, which according to the Saw classification, can be angiographically classified into 3 types.25 (Figure) The angiographic characteristics of type 1 SCAD include a dissection flap, false lumen appearance, contrast staining of the arterial wall, and late contrast clearing. Type 2 SCAD consists of a long diffuse (usually >30 mm) lesion with abrupt changes in the arterial caliber from its normal diameter to diffuse smooth narrowing. Type 2 SCAD can also be classified into type 2A (diffuse narrowing bordered by normal artery segments) and 2B (diffuse narrowing extending to the apical tip of the artery). Similar to atherosclerosis, the angiographic characteristics of type 3 SCAD include single or multiple focal stenoses attributable to intramural hematoma. In patients with high clinical suspicion for SCAD (eg, young women with AMI and no cardiovascular risk factors), SCAD should be initially evaluated by prompt coronary angiography, with particular emphasis on identifying type 1 and 2 SCAD. Intracoronary imaging such as optical coherence tomography (OCT) or intravascular ultrasound (IVUS) may be further required to distinguish between specific SCAD types, especially between type 3 SCAD and coronary atherosclerotic disease. The aforementioned angiographic classification assists with angiographic recognition of SCAD as an entity but does not direct the choice of therapy and has not been shown to impact outcomes. Patients with SCAD with completely occluded coronary arteries subtending a large area of jeopardized myocardium, cardiogenic shock, active/ongoing ischemia with persistent compromise in coronary blood flow, hemodynamic instability, ventricular arrhythmias, STEMI, and high‐risk anatomy (eg, TIMI flow 0–1, left main dissection and proximal dissection) should be considered for revascularization.1 In addition, the classification of SCAD by the presence or absence of IMH, presence of additional intimal dissections, and length/stenosis parameters can inform the clinician as to the patient's risk of early serious SCAD extension. In a retrospective study of 240 patients with SCAD, Waterbury et al found that the angiographic finding of isolated IMH (ie, absence of intimal tear) was associated with a higher risk of early clinically important extension of SCAD in patients treated with conservative management.2 Lesion length and stenosis severity were additional parameters that conferred a higher risk of acute extension. Angiographic features may be dynamic, as recurrent SCAD often involves coronary segments not affected previously and may manifest as a different angiographic type than that of the initial presentation.Download figureDownload PowerPointFigure 1. Spontaneous coronary artery dissection classification and revascularization challenges.SCAD indicates spontaneous coronary artery dissection.However, revascularization is associated with suboptimal procedural success rates and high rates of complications despite preserved coronary flow.19, 20, 26 Most importantly, revascularization strategies may not protect against future target vessel revascularization or recurrent SCAD.20 Overall, revascularization should be avoided, particularly in patients with low‐risk features (eg, no active ischemia, coronary dissection in an arterial segment subtending a small territory), because the majority of dissections in patients with SCAD will heal spontaneously. In a study of 156 patients with SCAD (182 lesions) who underwent repeat coronary angiography with a median time of 154 days (interquartile range, 70–604 days) for a variety of indications, 95% of SCAD lesions were healed when angiography was performed ≥30 days after the acute SCAD event.27Revascularization Strategies and TechniquesPrompt coronary revascularization is a cornerstone of SCAD management in the context of major coronary occlusion. However, SCAD has a different pathophysiological process involving a dissected artery, and percutaneous coronary intervention (PCI) for SCAD is associated with lower rates of procedural success, higher rates of disease‐specific technical challenges, and increased rates of complications compared with PCI for atherosclerotic acute coronary syndrome. Challenges include coronary artery fragility, iatrogenic dissection, wire entry into a false lumen, abrupt vessel occlusion, dissection extension, late strut mal‐apposition, and hematoma propagation with stent placement requiring additional unplanned stents19, 26 (Figure). Several small observational studies showed lower success rates and higher rates of complications in PCI for SCAD.13, 14, 18 In a study of 34 patients with SCAD who underwent PCI, 8 patients (24%) were complicated by propagation of the dissection flap, and in 2 patients there was an inability to pass the wire distally into the true lumen, leading to dissection with a lower final TIMI flow grade ultimately requiring emergent CABG.14 In a study of 56 patients with SCAD who were treated with revascularization (51 for PCI and 5 for CABG), 3 patients (5.8%) treated with PCI were switched to urgent CABG for procedural failure; one died from retrograde aortic dissection after PCI on the proximal LAD, and another patient died after emergency CABG for STEMI and multivessel SCAD complicated by cardiogenic shock.18 Among PCI‐treated patients, 5 had repeated percutaneous revascularization; one for late stent thrombosis, 2 for recurrent spontaneous dissection in other vessels, one for progression of dissection distal to the implanted stent, and one for restenosis.In a preliminary report from the Vancouver General Hospital SCAD registry, of all patients with SCAD with stents, 6.9% required bail‐out surgery, 1.4% had stents placed into the false lumen, 9.7% had iatrogenic dissection, and 2.8% suffered stent thrombosis.28 Compared with atherothrombotic STEMI, emergent PCI for SCAD‐related STEMI was associated with lower rates of achieving TIMI grade 3 flow (91% versus 98%, P=0.016) and a 9% failure rate (mostly related to the inability to access the true lumen or to residual stenosis >50%), with more and longer stents (mean stent length was 62±37 mm; range 12–140 mm) required for SCAD lesions.9 Thrombolytic therapy for SCAD‐related STEMI should be avoided because of the conceptual hazard of extension of the dissection or hematoma.In theory, compared with radial access, femoral access could be associated with more complications and bleeding given SCAD's propensity to affect young women and its association with fibromuscular dysplasia/arteriopathies. However, radial access may result in noncoaxial engagement in the coronary ostium, deep catheter engagement, and frequent need for more aggressive catheter manipulation.29 The American Heart Association Scientific Statement on SCAD recommends femoral access over radial access, and that extra caution be taken with radial catheterization if required. The study reported guide‐induced iatrogenic dissections occurred in 3 of 42 (7.1%) radial‐approach angiograms, including 2 extensive LM dissections requiring emergent CABG.30 In the Vancouver General Hospital SCAD registry, cases with iatrogenic coronary artery dissection had an increased proportion of radial access (50.0%) than non‐iatrogenic coronary artery dissection cases (16.4%; P=0.009), compared with femoral access.29CABG can be considered for unstable patients in certain specific scenarios (eg, left main dissections with ongoing ischemia/infarction, severe proximal 2‐vessel dissection, or in the case of PCI failure). CABG should also be considered when PCI is technically challenging or has been attempted and unsuccessful.31 One small study of patients with SCAD (5 left main dissections and 1 right coronary artery dissection) showed that all 5 patients with left main SCAD had favorable outcomes following CABG, while one patient with SCAD of the RCA died on the 30th postoperative day.32 Tweet et al demonstrated good early outcomes with CABG (n=20 patients with SCAD) and comparable 5‐year event rates to those treated conservatively.20 Although significant late graft occlusion occurred (11 of 16), perhaps because of restored flow from spontaneous healing over time, there was no further increase in mortality at 5 years.20 Notably, there is no evidence that CABG protects against recurrent SCAD, and conduit failure may occur because of poor distal targets affected by the SCAD. Clearly these studies are confounded by selection bias and the findings should be interpreted with caution. In addition, fragile and dissected coronary artery tissue may be more prone to anastomosis complications during CABG in patients with SCAD.31 Moreover, vein grafts should be considered to preserve arterial conduits for future use, if needed, in light of the high incidence of late graft failure attributable to expected native vessel healing.1A key concept in the revascularization of patients with SCAD is to reestablish coronary blood flow rather than restore normal coronary architecture (Table 2). In the absence of data from randomized controlled trials, most of the described revascularization techniques in patients with SCAD are based on clinical experience and expert opinion. For example, undersized balloon angioplasty may be considered to restore flow in focal and distal lesions, while fenestration of the intramural hematoma by regular or cutting balloon angioplasty may be considered to reduce the true lumen's compression12 in long and diffuse lesions. Some studies suggested that a hybrid approach using cutting balloon angioplasty and stenting may be considered for the compressive intramural hematoma to prevent late mal apposition once the hematoma is resorbed.33 Some consider the use of a non‐hydrophilic wire preferable to avoid extending the dissection by entering the false lumen.34 Some operators suggest that starting with a floppy wire and then escalating to a hydrophilic wire or a stiff wire, if needed, leads to a high rate of PCI success (up to 71.4%).34 IVUS and OCT may be considered to confirm the diagnosis, ensure proper positioning of the guidewire, confirm true lumen entry, and optimize stent parameters. IVUS can identify the false lumen in detail and reduce the use of contrast agents. On the other hand, OCT has a high resolution for confirming guidewire position, intramural hematoma location, and optimal stenting, but requires filling of the coronary artery with contrast media and thus carries a risk of hydraulic extension of the SCAD.25 Overall, IVUS and OCT should be encouraged for PCI in patients with SCAD as complications from these advanced imaging techniques in SCAD (eg, dissection of the imaged vessel and stent deformation) are rare. Undersized stents may increase the risk of restenosis and stent thrombosis once the hematoma has resolved, while oversized stents may cause an extension of the dissection flap. When treating long lesions, a multistep approach of stenting may be considered, for example stenting the distal edge followed by the proximal edge, and then finally stenting the middle portion of the dissected artery to avoid hematoma propagation. Only 1 study compared stent types in patients with SCAD. A non‐significant trend towards a lower rate of major adverse cardiovascular events occurrence in the drug‐eluting stent group was observed after a median follow‐up time of 3.3 years (17% versus 31%, P=0.11) compared with the bare metal stent group, a difference that was mainly driven by target‐vessel revascularization.35 Overall, IVUS and OCT are generally safe in patients with SCAD, and it is important to remember that stents do not prevent SCAD recurrence and may increase rates of repeat revascularization, especially when long stents are placed.20 Bioresorbable stents have been proposed because of their ability to preserve tissue biomechanics and recover the endothelial function, but data on their use in patients with SCAD are limited.36Table 2. Summary of Proposed Invasive Strategies and Post‐Revascularization CareInvasive StrategiesPost‐Revascularization CareIVUS or OCT guided wire and stent placement should be considered for identifying the compressed true lumen and stent optimizationRepeat angiography should be considered in patients with indication for angiography (eg, recurrent or ongoing chest pain) and revascularization is felt necessary for ongoing, unstable ischemia (or in the context of recurrent SCAD)Start with a floppy wire, particularly in patients with SCAD with TIMI 0/1, and then escalate to a hydrophilic wire or stiff wire if neededFollow‐up computerized tomography coronary angiography may also be considered medically managed patients, particularly with type 1 dissections, while follow‐up echocardiography should be considered if left ventricular systolic dysfunctionTo reduce the risk for catheter‐induced dissection, avoid deep catheter engagement, keep coaxial non‐deep catheter intubation, and limit the force of injectionBeta blockers are recommended in all patients with SCADIf possible, direct stenting without pre‐ and post‐dilatation to reduce risk of hematoma extension is preferred. If balloon angioplasty needed, a hybrid approach with cutting balloon to fenestrate the intimal flap before stent implantation should be consideredAngiotensin‐converting enzyme inhibitor/angiotensin‐receptor blocker should be considered if evidence of left ventricular systolic dysfunctionThree‐stent technique or multi‐stent approach should be considered by stenting the distal segment first followed by the proximal segment and finally the mid‐part to prevent hematoma extensionCardiac rehabilitation should be considered in all patients with SCADLong stents covering additional 5–10 mm on both proximal and distal edges beyond the margins of the dissection should be consideredColchicine is not routinely recommended but may be considered in inflammatory conditions related to SCAD (eg, eosinophilic coronary periarteritis)Avoid 1:1 vessel:stent sizing and optimal apposition and self‐expanding stents should be consideredReferral to a specialist in medical genetics may be considered (eg, genetic testing is often directed at identification of an underlying systemic arteriopathy or connective tissue disorder)John Wiley & Sons, LtdACS indicates acute coronary syndrome; IVUS, intravascular ultrasound; OCT, optical coherence tomography; SCAD, spontaneous coronary artery dissection; and TIMI, Thrombolysis in Myocardial Infarction.Mechanical Circulatory SupportCurrent literature on SCAD and cardiogenic shock with/without mechanical circulatory support is limited. In a systematic review of pregnancy‐associated SCAD, 29 patients with SCAD developed cardiogenic shock requiring placement of an intra‐aortic balloon pump and subsequently revascularization or heart transplant.37 In a case series of 4 patients with SCAD and cardiogenic shock, Impella provided valuable procedural support in those patients with cardiogenic shock, especially in cases without evidence of ongoing ischemia.38 In theory, mechanical circulatory support should be considered in SCAD patients with cardiogenic shock without evidence of ongoing ischemia (no need for revascularization) to temporarily support the myocardium while allowing SCAD vessels to heal independently. In addition, some cases demonstrate the beneficial use of mechanical circulatory support devices as a bridge to recovery or heart transplant in the setting of refractory cardiogenic shock because of SCAD.39 Several case reports demonstrate the feasibility of mechanical circulatory support using extracorporeal membrane oxygenation.40, 41 These cases provide additional data on the safety of venoarterial extracorporeal membrane oxygenation in the management of cardiogenic shock secondary to SCAD.Post‐Revascularization CareSeveral ongoing clinical trials and registries in patients with SCAD are currently underway (Table 3). Although a paucity of data on re‐imaging in patients with SCAD exists, repeat angiography should be considered in patients with an indication for angiography (eg, recurrent or ongoing chest pain), and revascularization is necessary for ongoing, unstable ischemia (or in the context of recurrent SCAD).1, 31 It takes time for dissected vessels to heal, and evidence of residual dissection in the absence of clinical ischemia would not be an indication for revascularization.1 Follow‐up computerized tomography coronary angiography can also be considered in medically managed patients, particularly those with type 1 dissections. No clinical trial data exist to guide the need and timeline for repeat imaging, the duration of DAPT, or the merits of other pharmacotherapies in patients with SCAD. The American Heart Association Scientific Statement on SCAD suggests using DAPT as one would base on current guidelines for non‐SCAD PCI.1 In individuals at higher risk of bleeding events, per the expert consensus, consideration of recommending DAPT for at least 2 to 4 weeks after SCAD and low‐dose aspirin alone is reasonable. Long‐term DAPT may be considered in cases of severe late‐acquired stent mal‐apposition observed at follow‐up.31 Aspirin and clopidogrel are generally used, given the higher risk of bleeding with the newer generation P2Y12 receptor inhibitors. In general, some experts recommended lifelong low‐dose aspirin DAPT for 1 year following the current guideline‐based therapy for acute coronary syndrome.32 In fact, the duration of DAPT therapy remains controversial and depends on the location of SCAD, revascularization modality, and the number and size of stents used. For example, there is a theoretical concern that antiplatelet therapy in patients with SCAD with IMH could potentially cause bleeding or dissection extension, even with low‐dose aspirin monotherapy. Further study of antiplatelet therapy in patients with SCAD is needed. Beta‐blockers may be considered in all patients with SCAD, as they likely help mitigate SCAD recurrence, possibly by reducing coronary arterial shear stress and reversing catecholamine‐mediated cardiac dysfunction.12 Angiotensin‐converting enzyme inhibitor/angiotensin‐receptor blocker and follow‐up echocardiography should be considered if evidence of left ventricular systolic dysfunction is present. Statin use in patients with SCAD remains controversial but should be considered in patients with elevated atherosclerotic risk. Cardiac rehabilitation may be considered in all patients with SCAD to expedite their recovery and improve quality of life.19Table 3. Current Ongoing Clinical Trials and Registries in Patients With SCADTrial or RegistryNo. (n)AimsExclusion CriteriaFollow‐UpStatusThe "Virtual" Multicenter SCAD Registry (NCT01429727)Estimated 900 participantsDescribe the clinical and physiologic characteristics of SCADLack of angiographic confirmation of SCAD Iatrogenic dissection or an alternate diagnosis10–15 yRecruitingCanadian SCAD Study (NCT02188069)750 participantsIn‐hospital outcome, follow‐up outcome of SCADPatients with troponin‐negative ACS or typical atherosclerotic coronary artery disease with diameter stenosis ≥50%3 yActive, not recruitingiSCAD Registry (NCT04496687)Estimated 1000 participantsDescribe the clinical and demographic characteristics of SCAD as well as clinical and psychological outcomesCoronary dissection in association with atherosclerosis or as a result of iatrogenic injury3 yRecruitingSAFER‐SCAD (Statin and Angiotensin‐converting Enzyme Inhibitor on Symptoms in Patients With SCAD) (NCT02008786)40 participants1) Rosuvastatin 10–20mg daily vs placebo 2) Ramipril vs placeboPatients with glomerular filtration rate <50 mL/min; prior intolerance or allergy to rosuvastatin or Ramipril; coronary flow reserve >3.0; coronary artery disease (stenosis >50% in any artery) or residual dissection >50% with distal flow abnormalitiesRecruitingAngiographic and Psychosocial Evaluation of Peripartum vs Non: SCAD (NCT03390998)241 participantsDetermine differences in clinical and imaging presentation, in‐hospital management and prognosis in peri‐partum and non‐peri‐partum patients with SCADMale patients or patients with not a known or suspected diagnosis of SCADCross‐sectionalSpontaneous Coronary Artery Dissection Registry (DIssezioni Spontanee COronariche ITalian‐SPAnish) (DISCO‐IT/SPA) (NCT04415762)314 participantsClinical characteristics, predisposing factors of SCAD, the incidence of SCAD recurrenceThe impact of a single antiplatelet therapy vs DAPT, impact of different angiographic SCAD type on outcomeAge <18 y or inability to provide informed consentRetrospectiveSpontaneous Coronary Artery Dissection National Swiss Registry (SwissSCAD) (NCT04457544)1000 participantsDemographic and procedural data in patients with SCADPatients with atherosclerotic or iatrogenic coronary dissection5 yRecruitingThe Study of the Prevalence Fibromuscular Dysplasia in Patient With Haematoma or Spontaneous Coronary Artery Dissection (DISCO) (NCT02799186)200 participantsPrevalence of the FMD in SCAD and predisposing factors of SCAD and FMDCoronary dissection with traumatic or iatrogenic originInterventionalSpanish Registry on Spontaneous Coronary Artery Dissection (SR‐SCAD) (NCT03607981)300 participantsTo assess clinical/angiographic characteristics, predisposing factors, associated conditions, risks of major adverse cardiovascular events and recurrent SCADUnable to provide informed consent.3 yRecruitingGenetics of Spontaneous Coronary Artery Dissection (SCAD‐INSPIRE Genetics) (NCT03876847)100 participantsTo determine genetic variants in patients with SCADThree cardiologists determine the coronary angiography was not a result of SCAD; poor quality images, heart, or bone marrow transplantCross‐sectionalEnrolling by invitationSpontaneous Coronary Artery Dissection anaLysIs of the Brazilian Updated Registry (SCALIBUR) (NCT03398850)250 participantsDemographic and angiographic characteristics, type of treatment, long‐term follow‐up in SCAD.Coronary dissections attributable to atherosclerotic plaque or trauma induced10 yRecruitingSCAD and Autoimmunity (NCT03941184)600 participantsTo determine whether SCAD is associated with autoimmune diseasesAdults aged <18 y or >110 yCase‐controlRecruitingDefining the Basis of Fibromuscular Dysplasia (DEFINE) (NCT01967511)600 participantsThe identification of regulatory gene networks, fibroblasts, DNA, plasma between FMD, SCAD, and CvADPatients with life expectancy to one year, organ transplantation, active autoimmune disease, Illicit drug use, HIV positive, prior malignancy, or PADCase‐controlRecruitingJohn Wiley & Sons, LtdACS indicates acute coronary syndrome; CvAD, cervical artery dissection; FMD, fibromuscular dysplasia; PAD, peripheral artery disease; and SCAD, spontaneous coronary artery dissection.ConclusionsAscertaining the appropriateness of revascularization, choosing the safest modality, and using optimal techniques are critically important in the treatment of patients with SCAD. Patients presenting with STEMI, hemodynamic instability, active/ongoing ischemia, sustained ventricular arrhythmias, cardiac arrest, proximal coronary occlusions, and those who progress to occlusion after initial conservative management should be considered for coronary revascularization. PCI is the most common revascularization strategy for SCAD. However, CABG may be considered in those with high‐risk features (eg, left main dissections with ongoing ischemia/infarction, severe proximal 2‐vessel dissection, or in the case of PCI failure). Lifelong low‐dose aspirin is recommended, and the duration of DAPT (preferably clopidogrel as a second antiplatelet agent) after stenting is tailored to the location of SCAD as well as the number and size of stents used. Beta‐blockers and cardiac rehabilitation are preferred in all patients with SCAD, while statins and angiotensin‐converting enzyme inhibitors/angiotensin‐receptor blockers may be considered selectively when other clinical indications exist.DisclosuresDr Krittanawong discloses the following relationships: Member of the American College of Cardiology Solution Set Oversight Committee, t

Orthotopic heart transplantation is the most effective long-term therapy for end-stage heart disease. Denervation with the loss of autonomic modulation, vasculopathy, utilization of immunosuppressant drugs, and allograft rejection may result in an increased prevalence of arrhythmias in transplanted hearts. We aim to describe the trends, distribution, and the clinical impact of arrhythmias in patients with transplanted hearts. We queried the National Inpatient Sample with administrative codes for cardiac transplant patients using procedure ICD-9-CM codes 37.5 and 33.6. Arrhythmias were extracted using validated ICD-9-CM codes. Statistical Analysis System (SAS) version 9.4 was used for analysis. There were a total of 30,020 hospitalizations of heart transplant recipients between 1999 and 2014 in the United States of which 1,6342 (54.4%) had an arrhythmia. The frequency of total arrhythmias increased from 53.6% (n=1,158) in 1999 to 67.3% (n=1,575) in 2014. Transplant patients with arrythmias was not associated with significantly higher inpatient mortality (7.72% vs 6.90%, P = 0.225). The most common arrythmia was atrial fibrillation ([AF]26.83%) followed by ventricular tachycardia (22.86%). Trends in mortality associated with arrhythmias following heart transplant has been decreasing from 12.3% in 1999 to 8.9% in 2014 (P = 0.04). Subgroup analysis of ventricular arrythmias (VA) following heart transplant were associated with increased mortality (8.61% vs 6.94%, P = 0.0229). Over half of patients develop 1 or more cardiac arrhythmia after heart transplant. There is an increasing secular trend in the frequency of arrhythmias post cardiac transplant with atrial fibrillation determined to be the most common arrhythmia.

Poor psychological health is associated with Takotsubo cardiomyopathy, cardiac syndrome X, coronary microcirculatory dysfunction, peripheral artery disease, or spontaneous coronary artery dissection. Data regarding pessimism, cardiovascular disease (CVD) events and mortality and all-cause mortality remained inconclusive. This systematic review and meta-analysis aim to provide an overview of the association between pessimism, CVD outcomes and mortality. A systematic search of electronic databases was conducted from inception through July 2022 for studies evaluating pessimism and adverse outcomes. A total of 17 studies published between 1966 and July 2022 met our inclusion criteria, for a total of 232,533 individuals. Pooled hazard ratios were calculated in random-effects meta-analyses. Based on pooled analysis of adjusted HRs, pessimism was associated with adjusted HR of 1.13 (95% CI 1.07-1.19) for all-cause mortality with minimal heterogeneity (I2 = 28.5%). Based on pooled analysis of adjusted HRs, pessimism was associated with adjusted HR of 1.30 (95% CI 0.43-3.95) for CHD mortality, adjusted HR of 1.41 (95% CI 1.05-1.91) for CVD mortality, and adjusted HR of 1.43 (95% CI 0.64-3.16) for stroke. In conclusion, pessimism seems to be significantly associated with a higher risk for and poorer outcomes from CVD events than optimistic styles. There are genetic and other bases for these life approaches, but behavioral, cognitive and meditative interventions can modify patients' level of pessimism, hopefully leading to better medical outcomes. Testing this theory would yield highly useful and practical data for clinical care.

Noise is considered an environmental stressor adversely affecting well-being and quality of life, inter-individual communications, and attention and cognitive function and inducing emotional responses, corresponding to noise annoyance. In addition, noise exposure is associated with non–auditory effects including worsening mental health, cognitive impairments, and adverse birth outcomes, sleep disorders, and increased annoyance. An accumulating body of evidence has indicated that traffic noise is also associated with CVD, through multiple pathways. It has been shown that psychological stress and mental health disorders such as depression and anxiety have a negative impact on the development of cardiovascular diseases and outcomes. Likewise, reduced sleep quality and/or duration has been reported to increase sympathetic nervous system activity, which can predispose to conditions like hypertension and diabetes mellitus, known risk factors for CVD. Finally, there seems to be a disruption in the hypothalamic-pituitary-axis secondary to noise pollution that also results in an increased risk of CVD. The World Health Organization has estimated that the number of DALYs (disability-adjusted life-years) lost resulting from environmental noise in Western Europe ranges from 1 to 1.6 million, making noise the second major contributor to the burden of disease in Europe, only after air pollution. Thus, we sought to explore the relationship between noise pollution and risk of CVD.

Cardiovascular disease (CVD) remains the leading cause of death worldwide. Serum lipoprotein(a) (Lp(a)) has been shown to be an independent and causative risk factor for atherosclerotic CVD and calcific aortic valvular disease. Lp(a) continues to be studied, with emerging insights into the epidemiology of CVD with respect to Lp(a), pathogenic mechanisms of Lp(a) and strategies to mitigate disease. There have been novel insights into genetic polymorphisms of the LPA gene, interactions between concomitant risk factors and Lp(a) based on real-world data, and metabolic pathway targets for Lp(a) reduction. This review highlights these recent advances in our understanding of Lp(a) and discusses management strategies as recommended by cardiovascular professional societies, emerging therapies for lowering Lp(a), and future directions in targeting Lp(a) to reduce CVD.

Data science is likely to lead to major changes in cardiovascular imaging. Problems with timing, efficiency, and missed diagnoses occur at all stages of the imaging chain. The application of artificial intelligence (AI) is dependent on robust data; the application of appropriate computational approaches and tools; and validation of its clinical application to image segmentation, automated measurements, and eventually, automated diagnosis. AI may reduce cost and improve value at the stages of image acquisition, interpretation, and decision-making. Moreover, the precision now possible with cardiovascular imaging, combined with “big data” from the electronic health record and pathology, is likely to better characterize disease and personalize therapy. This review summarizes recent promising applications of AI in cardiology and cardiac imaging, which potentially add value to patient care.

Objectives To examine the prognostic significance of atrial fibrillation (AF) versus sinus rhythm (SR) on the management and outcomes of patients with severe aortic stenosis (AS). Methods 1847 consecutive patients with severe AS (aortic valve area ≤1.0 cm 2 and aortic valve systolic mean Doppler gradient ≥40 mm Hg or peak velocity ≥4 m/s) and left ventricular ejection fraction ≥50% were identified. The independent association of AF and all-cause mortality was assessed. Results Age was 76±11 years and 46% were female; 293 (16%) patients had AF and 1554 (84%) had SR. In AF, 72% were symptomatic versus 71% in SR. Survival rate at 5 years for AF (41%) was lower than SR (65%) (age- and sex-adjusted HR=1.66 (1.40–1.98), p&lt;0.0001). In multivariable analysis, factors associated with mortality included age (HR per 10 years=1.55 (1.42–1.69), p&lt;0.0001), dyspnoea (HR=1.58 (1.33–1.87), p&lt;0.0001), ≥ moderate mitral regurgitation (HR=1.63 (1.22–2.18), p=0.001), right ventricular systolic dysfunction (HR=1.88 (1.52–2.33), p&lt;0.0001), left atrial volume index (HR per 10 mL/m 2 =1.13 (1.07–1.19), p&lt;0.0001) and aortic valve replacement (AVR) (HR=0.44 (0.38–0.52), p&lt;0.0001). AF was not a predictor of mortality independent of variables strongly correlated HR=1.02 (0.84–1.25), p=0.81). The 1-year probability of AVR following diagnosis of severe AS was lower in AF (49.8%) than SR (62.5%) (HR=0.73 (0.62–0.86), p&lt;0.001); among patients with AF not referred for AVR, symptoms were frequently attributed to AF instead of AS. Conclusion AF was associated with poor prognosis in patients with severe AS, but apparent differences in outcomes compared with SR were explained by factors other than AF including concomitant cardiac abnormalities and deferral of AVR due to attribution of cardiac symptoms to AF.

Personalized MedicineVol. 16, No. 2 CommentaryHow artificial intelligence could redefine clinical trials in cardiovascular medicine: lessons learned from oncologyChayakrit Krittanawong, Kipp W Johnson & WH Wilson TangChayakrit Krittanawong*Author for correspondence: Tel.: +1 212 523 4000; Fax: +1 212 523 8605; E-mail Address: Chayakrit.Krittanawong@mountsinai.org Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA, Kipp W Johnson Department of Genetics & Genomic Sciences, Institute for Next Generation Healthcare, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA & WH Wilson Tang Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, OH, 44195, USA Department of Cellular & Molecular Medicine, Lerner Research Institute, Cleveland, OH, 44195, USA Center for Clinical Genomics, Cleveland Clinic, Cleveland, OH, 44195, USAPublished Online:6 Mar 2019https://doi.org/10.2217/pme-2018-0130AboutSectionsView ArticleView Full TextSupplemental MaterialPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInReddit View articleKeywords: artificial intelligenceclinical trialsdeep learningmachine learningprecision cardiovascular medicineprecision medicinePapers of special note have been highlighted as: • of interest; •• of considerable interestReferences1 Sedgwick P. 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SpringerNature, Switzerland AG, 239–278 (2016). https://link.springer.com/book/10.1007/978-3-319-42448-4.Crossref, Google ScholarFiguresReferencesRelatedDetailsCited ByArtificial Intelligence Applied to clinical trials: opportunities and challenges28 February 2023 | Health and Technology, Vol. 13, No. 2Artificial Intelligence and Machine Learning‐Based Manufacturing and Drug Product Marketing7 February 2023The next generation of evidence-based medicine16 January 2023 | Nature Medicine, Vol. 29, No. 1Scoping review of the current landscape of AI-based applications in clinical trials12 August 2022 | Frontiers in Public Health, Vol. 10Cardiac Ultrasound Imaging: The Role of Artificial Intelligence22 April 2022Towards Network Medicine: Implementation of Panomics and Artificial Intelligence for Precision Medicine24 June 2022Artificial intelligence and machine learning in cardiovascular computed tomographyWorld Journal of Cardiology, Vol. 13, No. 10Applying advanced technologies to improve clinical trials: a systematic mapping study21 November 2020 | Scientometrics, Vol. 126, No. 2Therapeutic implications of statins in heart failure with reduced ejection fraction and heart failure with preserved ejection fraction: a review of current literature12 January 2021 | F1000Research, Vol. 10The Role of Artificial Intelligence in Cardiovascular Imaging: State of the Art Review23 December 2020 | Frontiers in Cardiovascular Medicine, Vol. 7Cardioinformatics: the nexus of bioinformatics and precision cardiology4 December 2019 | Briefings in Bioinformatics, Vol. 21, No. 6Improving Mental Health Services: A 50-Year Journey from Randomized Experiments to Artificial Intelligence and Precision Mental Health26 July 2020 | Administration and Policy in Mental Health and Mental Health Services Research, Vol. 47, No. 5Fundamentals in Artificial Intelligence for Vascular SurgeonsAnnals of Vascular Surgery, Vol. 65 Vol. 16, No. 2 Follow us on social media for the latest updates Supplemental MaterialsMetrics Downloaded 370 times History Received 1 November 2018 Accepted 10 December 2018 Published online 6 March 2019 Published in print March 2019 Information© 2019 Future Medicine LtdKeywordsartificial intelligenceclinical trialsdeep learningmachine learningprecision cardiovascular medicineprecision medicineSupplementary dataTo view the supplementary data that accompany this paper please visit the journal website at: www.futuremedicine.com/doi/full/10.2217/pme-2018-0130AcknowledgmentsThe authors thank Martin S Tallman (Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, NY, USA), for oncology consultations and criticism of the manuscript.Financial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.PDF download

Nonalcoholic fatty liver disease (NAFLD) and cardiovascular diseases are both highly prevalent conditions around the world, and emerging data have shown an association between them. This review found several longitudinal and cross-sectional studies showing that NAFLD was associated with coronary artery disease, cardiac remodeling, aortic valve remodeling, mitral annulus valve calcifications, diabetic cardiomyopathy, diastolic cardiac dysfunction, arrhythmias, and stroke. Although the specific underlying mechanisms are not clear, many hypotheses have been suggested, including that metabolic syndrome might act as an upstream metabolic defect, leading to end-organ manifestations in both the heart and liver. Management of NAFLD includes weight loss through lifestyle interventions or bariatric surgery, and pharmacological interventions, often targeting comorbidities. Although there are no Food and Drug Administration-approved nonalcoholic steatohepatitis-specific therapies, several drug candidates have demonstrated effect in the improvement in fibrosis or nonalcoholic steatohepatitis resolution. Further studies are needed to assess the effect of those interventions on cardiovascular outcomes, the major cause of mortality in patients with NAFLD. In conclusion, a more comprehensive, multidisciplinary approach to diagnosis and management of patients with NAFLD and cardiovascular diseases is needed to optimize clinical outcomes.

An overview of the use of artificial intelligence (AI) in general hospital medicine is given in this chapter, with a particular emphasis on high-value treatment, perioperative management, patient safety and quality issues, screening, vaccine recommendations, and telemedicine. AI has the potential to deliver standardized care more accurately and effectively. AI helps with risk assessment and therapy optimization in perioperative care. However, there are still issues with data accessibility and disease-specific checks. AI can help with patient safety and quality issues, but medication and diagnostic errors must be addressed. AI screening has also demonstrated promise for several internal medicine diseases, including cancer, diabetes, diabetes-related conditions, cardiovascular disease, and mental health issues. AI can also help with telehealth and vaccine development, facilitating remote diagnosis and enhancing patient access to care. However, further research is required to address the modifications in the hospital setting and technology accessibility.

This chapter discusses the use of AI in interventional cardiology. The chapter outlines how machine learning is focused on building automated clinical decision systems that help physicians make more accurate predictions, rather than those obtained through simplified estimated scoring systems. Studies illustrating the promise of AI techniques, such as Deep Learning (DL) and computer vision, for image quantification in cardiology are discussed and recent developments in the use of Machine Learning (ML) for physiologic measurements are also summarized. Studies showing the use of ML in intravascular ultrasound (IVUS) imaging technology are summarized, with examples describing the accurate diagnosis of angiographic lesions, plaque characterization, microvascular dysfunction, and post-procedural stent area and the performance of IVUS-based ML algorithms compared with that of human experts. The chapter discusses how AI-assisted precision PCI is an extremely promising area within interventional cardiology in order to optimize lesion preparation, obtain complete revascularization and, achieve a durable long-term result, and examples of how AI can aid in this area are given. The use of AI models for risk stratification and outcome prediction in cardiology is described, and a selection of studies in this area is summarized. The use of DL in robotic-assisted procedures is also touched upon briefly. The use of Natural Language Processing (NLP) to predict post PCI outcomes is described and the possible utilization of augmented reality and AI to assist in medical education and catheterization laboratory training, such as procedural training, procedural assistance, and patient or physician education is also outlined. The potential for AI to detect and identify various challenging cardiological conditions is also discussed. The chapter ends by discussing the challenges for the use of AI-assisted decision-making, and providing a brief overview of the future of AI-integrated interventional cardiology.

An overview of the promise, restrictions, and difficulties of artificial intelligence (AI) in revolutionizing primary care is given in this chapter. The application of AI, machine learning, and deep learning in healthcare has made significant strides in several primary care domains, including screening, preoperative care, and disease diagnosis. Numerous diseases, including cancer, cardiovascular disease, sexually transmitted diseases, osteoporosis, diabetes mellitus, hypertension, ophthalmic diseases, and obstructive sleep apnea, have been successfully predicted, diagnosed, and risk assessed using AI models. For the widespread adoption of AI in primary care, issues including data quality, interpretability, and regulatory constraints must be resolved. Nevertheless, by enhancing disease diagnosis, risk assessment, and personalized care, AI has the potential to transform primary care.

Even with modern advancements in the management of acute mesenteric ischemia over the past decade, morbidity and mortality remain high, and the best primary treatment modality is still debated amongst interventionalists. Traditionally, interventionalists have favored an open surgical approach but are now trending for endovascular interventions due to apparent reduced mortality and complications. Newer studies suggest hybrid approaches, and intestinal stroke centers may be superior to either strategy alone. This narrative review will explore the natural history of acute mesenteric ischemia with the aim of increasing interventionalist awareness of modern advancements in revascularization strategies for this devastating disease.

Significant left main coronary artery disease is a very high-risk subgroup of coronary artery disease that is a crucial indicator of heightened morbidity and mortality rates. Despite its clinical significance, uncertainties persist regarding the optimal management strategy for patients, particularly given its phenotypic variations. Existing evidence-based guidelines offer insights into revascularization options, yet questions remain regarding long-term prognoses and clinical outcomes when comparing percutaneous coronary intervention to coronary artery bypass grafting. This comprehensive review aims to provide an in-depth analysis of contemporary strategies for the diagnosis, assessment, and treatment of left main coronary artery disease. By synthesizing current literature and addressing the evolving landscape of revascularization modalities, this review seeks to contribute valuable insights for clinicians and researchers grappling with the complexities of managing left main coronary artery disease.

<h2>Abstract</h2><h3>Background</h3> Rotational atherectomy (RA) is used to address complex calcified coronary lesions but data regarding the association between gender and outcomes of patients undergoing RA remained uncertain. We aimed to investigate the short and long-term outcomes of patients undergoing RA based on sex. <h3>Methods</h3> A systematic literature search was performed in PubMed, Embase and Cochrane databases from its inception until August 2023 for relevant studies. Endpoints were pooled using the DerSimonian and Laird random-effects model as odd ratio (OR) with 95% confidence intervals (CI). <h3>Results</h3> 7 studies with 8,490 patients (2,565 women and 5,925 men) undergoing RA were included in the study. In terms of periprocedural outcomes, women had a higher risk of in-hospital mortality (OR 2.00, 95% CI 1.08-3.68, p=0.03), coronary dissection (OR 1.80, 95% CI 1.05-3.10, p=0.03), coronary perforation (OR 1.96, 95% CI 1.19-3.23, p=0.01), and stroke (OR 4.22, 95% CI 1.06-16.82, p=0.04) compared to men. There were no significant differences between women and men in terms of MACE (OR 1.43, 95% CI 0.69-2.94, p=0.33), MI (OR 1.35, 95% CI 0.87-2.08, p=0.18), bleeding (OR 1.71, 95% CI 0.88-3.30, p=0.11), and cardiac tamponade (OR 2.30, 95% CI 0.45-11.68, p=0.32). Over a follow-up period of 3 years, results of meta-analysis showed that women had a higher risk of all-cause mortality (OR 1.45, 95% CI 1.19-1.77, p<0.001), long-term MACE (OR 1.38, 95% CI 1.10-1.74, p=0.01), and long-term stroke (OR 3.41, 95% CI 1.63-7.17, p<0.001). The risk of long-term MI was found to be similar between both gender (OR 1.45, 95% CI 0.95-2.22, p=0.09). <h3>Conclusion</h3> In conclusion, female gender is associated with adverse periprocedural and long-term outcome following RA. Women consistently demonstrated higher risk of in-hospital mortality, coronary dissection, coronary perforation, and stroke in the periprocedural period. Long-term follow-up further highlighted a heightened risk for women in terms of all-cause mortality and stroke.

This case report discusses a diagnosis of spontaneous coronary artery dissection in an otherwise healthy man with non–ST elevation myocardial infarction.

ObjectiveNative aortic valve calcium and transcatheter aortic valve oversize have been reported to predict pacemaker implantation after transcatheter aortic valve insertion. We reviewed our experience to better understand the association.MethodsWe retrospectively reviewed the records of 300 patients with no prior permanent pacemaker implantation who underwent transcatheter aortic valve insertion from November 2008 to February 2015. Valve oversize was calculated using area. The end point of the study was 30-day postoperative pacemaker implantation.ResultsPatient data included age of 81.1 ± 8.4 years, female sex in 135 patients (45%), atrial fibrillation in 74 patients (24.7%), Society of Thoracic Surgeons predicted risk of mortality of 7.6% (interquartile range [IQR], 5.3-10.6), aortic valve calcium score of 2568 (IQR, 1775-3526) Agatston units, and annulus area of 471 ± 82 mm2. Balloon-expandable valves were inserted in 244 patients (81.3%). Transcatheter aortic valve oversize was 12.8% (IQR, 3.9-23.3). Pacemaker implantation was performed in 59 patients (19.7%). Aortic valve calcium score (adjusted P = .275) and transcatheter valve oversize (adjusted P = .833) were not independent risk factors for pacemaker implantation when controlling for preoperative right bundle branch block (adjusted odds ratio, 3.49; 95% confidence interval, 1.61-8.55; P = .002), implantation of self-expanding valve (adjusted odds ratio, 4.09; 95% confidence interval, 1.53-10.96; P = .005), left bundle branch block (adjusted P = .331), previous percutaneous coronary intervention (adjusted P = .053), or valve surgery (adjusted P = .111), and PR interval (adjusted P = .350).ConclusionsRight bundle branch block and implantation of a self-expanding prosthesis were predictive of pacemaker implantation, but not native aortic valve score or transcatheter valve oversize.

Summary The development of the promising agent sacubitril/valsartan, known as an angiotensin receptor blocker‐neprilysin inhibitor ( ARNI ), to improve heart failure ( HF ) management, may benefit morbidity, mortality, and readmission rates in patients with HF . The PARADIGM ‐ HF trial demonstrated that the ARNI can reduce morbidity and mortality in patients with heart failure with reduced ejection fraction ( HF r EF ), while ongoing PARAMOUNT and PARAGON ‐ HF trials determined whether the ARNI has morbidity and mortality benefits in patients with heart failure with preserved ejection fraction ( HF p EF ). However, the risk of long‐term side effects of the ARNI such as cognitive dysfunction or Alzheimer's disease ( AD ) remains unknown. In fact, neprilysin ( NEP ), encoded by NEP or MME gene, is a principal peptidase involved in the degradation of β‐amyloid (Aβ) protein. Several studies have demonstrated that polymorphisms of the NEP gene may be associated with AD and cerebral amyloid angiopathy ( CAA ). Pharmacogenomics, the study of variability in drug response due to genetic polymorphisms, can potentially explain the variability in the effect of the ARNI and their side effects. Therefore, we have attempted to highlight pharmacogenomic factors and potential long‐term side effects of the ARNI . Physicians should carefully monitor elderly patients with genetic risk factors for AD and CAA . In the future, genetic testing and genomic testing for NEP polymorphisms may play an important role in monitoring long‐term side effects in ARNI ‐treated HF patients.

Abstract Physical activity is associated with a lower risk of coronary heart disease/cardiovascular disease mortality, and current guidelines recommend physical activity for primary prevention in healthy individuals and secondary prevention in patients with coronary heart disease/cardiovascular disease. Over the last decade, playing classic video games has become one of the most popular leisure activities in the world, but is associated with a sedentary lifestyle. In the new era of rapidly evolving augmented reality technology, Pokémon Go, a well-known augmented reality game, may promote physical activity and prevent cardiovascular disease risks – that is, diabetes, obesity, and hypertension. Pokémon Go makes players willing to be physically active for regular and long periods of time. We report on an assessment of regular walking and playing Pokémon Go by performing data mining in Twitter.

Introduction: Cardiovascular diseases (CVDs) are chronic, heterogeneous diseases which are generally classified according to clinical presentation. However, the arrival of big data and analytical methods presents an opportunity to better understand these disease entities.Areas covered: This review article highlights: (1) the potential of a big data approaches with emerging technology to explore the heterogeneity of CVDs; (2) current challenges of a big data approach; and (3) the future of precision cardiovascular medicine.Expert commentary: Overall, most of the current data utilizing big data techniques remain largely descriptive and retrospective. Precision medicine, or N-of-1, approaches have not yet allowed for consistent interpretation since there is no ‘standard’ of how to best apply treatment approaches in a field where evidence-based medicine is based largely on randomized controlled trials. The risk score and biomarker-based approaches have been utilized with some ‘validation’ studies, but more in-depth biomarkers (i.e. pharmacogenomic biomarkers) have failed to demonstrate incremental benefits. Exploring novel CVD phenotypes by integrating existing medical variables, multi-omics, lifestyle, and environmental data using artificial intelligence is vitally important and may allow us to digitize future clinical trials, potentially leading to novel therapies.

This study was designed to explore the protective effect of 2,3,5,4'-tetrahydroxystilbene-2-O-β-d-glucoside (TSG) against ischemia/reperfusion (I/R) injury-induced cardiomyocytes apoptosis.The H9c2 cell I/R injury model was induced by simultaneous shortage of nutrients and oxygen. TSG administration (0.10, 0.25, and 0.50 mM) was performed before and during I/R stimulation. Cell apoptosis was evaluated using terminal deoxynucleotidyl transferase dUTP nick end labeling assay. Expression of cell-related proteins was detected to assess the effect of TSG on cell apoptosis.I/R injury induced significant cell apoptosis. Significantly decreased Bcl-2 and increased Bax, caspase-3, and p-Akt expression ( P < 0.01) was detected in the cell model of I/R injury. In contrast, TSG administration eliminated all the changes induced by I/R injury in a dose-dependent manner. Compared with the H9c2 cell model of I/R injury, the H9c2 cells treated with 0.50 mM TSG showed the lowest cell apoptosis percentage, the highest expression of Bcl-2, and the lowest expression of Bax, caspase-3, and p-Akt ( P < 0.01).We confirmed that the protective effect of TSG against I/R injury-induced cell apoptosis in H9c2 in vitro was associated with the Bcl-2/Bax ratio, caspase-3, and Akt activation.

<h2>Abstract</h2> There have been inconsistent reports regarding the clinical features and characteristics of patients diagnosed with spontaneous coronary artery dissection (SCAD). In addition, predictors of mortality in SCAD patients are unknown. We evaluated the prevalence, clinical characteristics, medical management, and predictors of in-hospital mortality of SCAD-related hospitalizations using data from a single health care system from January 1, 2008, to December 31, 2018. Among 30,425 patients who presented with an acute coronary syndrome, 375 (1.2%) patients were diagnosed with SCAD. Of these, the mean age was 52.2 ± 12.8 years, 64.3% were women, and 44% were white. SCAD was significantly associated with emotional stress, fibromuscular dysplasia (FMD), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), peripheral artery disease (PAD), and carotid artery disease compared with non-SCAD acute coronary syndrome (all <i>p</i>-values < 0.05). Multivariable analysis showed that atrial fibrillation (OR 2.56; 95% CI 1.01–6.23; <i>p</i> = 0.04), steroid use (OR 7.11; 95% CI 1.31–31.2; <i>p</i> = 0.01), ventricular arrhythmias (OR 4.53; 95% CI 1.58–12.3; <i>p</i> = 0.003), and cardiac arrest (OR 16.82; 95% CI 5.14–56.5; <i>p</i> < 0.001) were independent predictors of in-hospital mortality in SCAD patients. In conclusion, SCAD is an uncommon diagnosis that should be considered across all ages and both sexes and in patients with FMD, carotid artery disease, or PAD. Cardiac arrest, ventricular arrhythmia, steroid use, and atrial fibrillation were independently associated with in-hospital mortality in patients with SCAD.

Although most prevalent in elderly, myocardial infarction (MI) also affects younger adults. We sought to investigate baseline characteristics in young patients (<55 years) with MI using the National Inpatient Sample (NIS) database between 2004 and 2015. Multivariable logistic regression models were used to assess factors associated with acute myocardial infarction (AMI) in young patients. After multivariable analyses adjusted for age, sex, race, family history of atherosclerosis, body mass index (BMI), diabetes, hypertension, hyperlipidemia, chronic kidney disease, and current cigarette smoking; novel risk factors such as human immunodeficiency virus (HIV), systemic lupus erythematosus (SLE), and obstructive sleep apnea (OSA) were associated with a higher risk of developing an AMI in the young (adjusted OR for HIV 4.06; 95 CI 3.48-4.71, p < 0.001), (adjusted OR for SLE 2.12; 95 CI 1.89-2.39, p 0.04), and (adjusted OR for OSA 1.16; 95 CI 1.12-1.20, p < 0.001), respectively. Rheumatoid arthritis was associated with a lower risk of AMI (adjusted OR 0.83; 95 CI 0.76-0.89, p < 0.001). After multivariable analyses, cigarette smoking (adjusted OR 1.98; 95 CI 1.95-2.02, p < 0.001), obesity (adjusted OR 1.37; 95 CI 1.33-1.41, p = 0.003), hyperlipidemia (adjusted OR 1.07; 95 CI 1.04-1.08, p < 0.001) and a family history of CAD (adjusted OR 1.35; 95 CI 1.3-1.4, p < 0.001) were also associated with a higher risk of developing an AMI in the young. In conclusion, young patients with AMI have both traditional risk factors and non-traditional risk factors. In addition to traditional risk factors, close attention should be paid to emerging risk factors such as SLE, HIV and OSA.

In December 2019, an unprecedented outbreak of pneumonia cases associated with acute respiratory distress syndrome (ARDS) first occurred in Wuhan, Hubei Province, China. The disease, later named Coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO), was caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), and on January 30, 2020, the WHO declared the outbreak of COVID-19 to be a public health emergency. COVID-19 is now a global pandemic impacting more than 43,438,043 patients with 1,158,596 deaths globally as of August 26th, 2020. COVID-19 is highly contagious and has caused more deaths than SARS in 2002-2003 or the Middle East Respiratory Syndrome (MERS) in 2012-2013 combined and represents an unprecedented human affliction not seen since the influenza pandemic of 1918. COVID-19 has been associated with several cardiac complications, including hypercoagulability, acute myocardial injury and myocarditis, arrhythmias, and acute coronary syndromes. Patients with pre-existing cardiovascular disease (CVD) are at the highest risk for myocardial injury and mortality among infected patients. The mechanism by which COVID-infected patients develop cardiac complications remains unclear, though it may be mediated by increased ACE-2 gene expression. Despite initial concerns, there is no evidence that angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy increases risk for myocardial injury among those infected with COVID-19. In the current report, we summarize the peer-reviewed and preprint literature on cardiovascular risks and complications associated with COVID-19, as well as provide insights into its pathogenesis and management.

This study sought to identify electrocardiographic (ECG) and clinical predictors of sudden cardiac arrest (SCA) in sarcoidosis.Sudden cardiac death (SCD) is the leading cause of death in cardiac sarcoidosis (CS) and may be the earliest manifestation of disease. Widespread or repeated advanced imaging is a challenging solution to this problem. ECG is an affordable and widely accessible modality that could help guide diagnostic approaches and risk stratification.Data were obtained from the National Inpatient Sample (2005-2017) using International Classification of Diseases-9th Revision and -10th Revision-Clinical Modification. The primary outcome was to identify predictors of SCA, whereas predictors of SCA in young individuals and those with normal ventricular function served as secondary measures. Furthermore, temporal trends in sarcoidosis as well as SCA were also analyzed. Logistic regression analysis was used to calculate odds ratios, following which a multivariable regression was used to adjust for potential confounders.Electrocardiographic markers of AV node dysfunction or bundle branch block are associated with substantially increased risk of SCA in a limited proportion of patients (8.6%). This association is also observed among younger patients (<40 years) and those with normal ventricular function.ECG evidence of AV nodal dysfunction or distal conduction disease should raise suspicion for cardiac involvement in patients with sarcoidosis and are associated with increased risk of SCA. ECG markers could help identify patients who would benefit from advanced imaging. The sensitivity of ECGs is, however, limited and presence of a normal ECG does not reflect a low risk of SCA.

Functional decline due to skeletal muscle abnormalities leads to poor outcomes in patients with acute heart failure (AHF). The 6-minute walking test (6MWT) reliably evaluates functional capacity, but its technical difficulty for the elderly often limits its benefits. Although the Short Physical Performance Battery (SPPB) is a comprehensive measure of physical performance, its role in AHF remains unclear. This study aimed to examine the prognostic significance of SPPB compared to the 6MWT in elderly patients hospitalized for AHF.We retrospectively analysed 1192 elderly patients with AHF whose SPPB and 6MWT were measured during the hospitalization. The primary outcome measure was defined as a composite of all-cause death and heart failure readmission until 1 year after discharge. Patients with lower SPPB scores (0-6, n = 373) had significantly poorer outcomes than those with higher SPPB scores (7-12, n = 819) even after multivariable adjustment [adjusted hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.01-1.61; P = 0.049], similar to those with shorter 6MWT (<median) than those with longer 6MWT (adjusted HR 1.61, 95% CI 1.27-2.04; P < 0.001). Although both SPPB and 6MWT [net reclassification index (NRI) 0.139, P = 0.036 and NRI 0.350, P < 0.001, respectively] exhibited incremental prognostic value over conventional risk factors of HF, the additive prognostic effect of 6MWT was superior to that of SPPB (NRI 0.300, P < 0.001).Reduced functional capacity assessed by either the SPPB or 6MWT was associated with worse outcomes in hospitalized elderly patients with AHF. The incremental prognostic value over the conventional risk factors was higher in 6MWT than in SPPB.UMIN000023929.

Access to health care is affected by social determinants of health. The social vulnerability index encompasses multiple social determinants of health simultaneously and may therefore be associated with healthcare access.Cross-sectional data were used from the 2016‒2019 Behavioral Risk Factor Surveillance System, a nationally representative U.S. telephone-based survey of adults aged ≥18 years. State-level social vulnerability index was derived using county-level social vulnerability index estimates from the Centers for Disease Control and Prevention Agency for Toxic Substances and Disease Registry. Analyses were performed in October 2021. Social vulnerability index was ranked according to percentiles, which were divided into tertiles: Tertile 1 (0.10-0.32), Tertile 2 (0.33-0.53), and Tertile 3 (0.54-0.90).In multivariable-adjusted models comparing U.S. states in Tertile 3 with those in Tertile 1 of social vulnerability index, there was a higher prevalence of absence of healthcare coverage (OR=1.39 [95% CI=1.22, 1.58]), absence of primary care provider (OR=1.34 [95% CI=1.22, 1.48]), >1-year duration since last routine checkup (OR=1.18 [95% CI=1.10, 1.27]), inability to see a doctor because of cost (OR=1.38 [95% CI=1.23, 1.54]), and the composite variable of any difficulty in accessing healthcare (OR=1.15 [95% CI=1.08, 1.22]).State-level social vulnerability is associated with several measures related to healthcare access. These results can help to identify targeted interventions to improve access to health care in U.S. states with high social vulnerability index burden.

The Coronavirus disease 2019 (COVID-19) infection predisposes patients to develop deep vein thrombosis (DVT) and pulmonary embolism (PE). In this study, we compared the in-hospital outcomes of patients with DVT and/or PE with concurrent COVID-19 infection vs those with concurrent flu infection. The National Inpatient Sample from 2019 to 2020 was analyzed to identify all adult admissions diagnosed with DVT and PE. These patients were then stratified based on whether they had concomitant COVID-19 or flu. We identified 62,895 hospitalizations with the diagnosis of DVT and/or PE with concomitant COVID-19, and 8155 hospitalizations with DVT and/or PE with concomitant flu infection. After 1:1 propensity score match, the incidence of cardiac arrest and inpatient mortality were higher in the COVID-19 group. The incidence of cardiogenic shock was higher in the flu group. Increased age, Hispanic race, diabetes, chronic kidney disease, arrhythmia, liver disease, coagulopathy, and rheumatologic diseases were the independent predictors of mortality in patients with DVT and/or PE with concomitant COVID-19.

Exponential growth in data storage and computational power is rapidly narrowing the gap between translating findings from advanced clinical informatics into cardiovascular clinical practice. Specifically, cardiovascular imaging has the distinct advantage in providing a great quantity of data for potentially rich insights, but nuanced interpretation requires a high-level skillset that few individuals possess. A subset of machine learning, deep learning (DL), is a modality that has shown promise, particularly in the areas of image recognition, computer vision, and video classification. Due to a low signal-to-noise ratio, echocardiographic data tend to be challenging to classify; however, utilization of robust DL architectures may help clinicians and researchers automate conventional human tasks and catalyze the extraction of clinically useful data from the petabytes of collected imaging data. The promise is extending far and beyond towards a contactless echocardiographic exam-a dream that is much needed in this time of uncertainty and social distancing brought on by a stunning pandemic culture. In the current review, we discuss state-of-the-art DL techniques and architectures that can be used for image and video classification, and future directions in echocardiographic research in the current era.

Celiac disease (CD) is a chronic autoimmune disorder that affects the small intestine in genetically predisposed individuals. Previous studies have investigated the potential link between CD and cardiovascular disease (CVD); however, the findings have been inconsistent. We aimed to provide an updated review of the literature on the association between CD and CVD. PubMed was searched from inception to January 2023 using keywords including CD, cardiovascular disease, coronary artery disease, cardiac arrhythmia, heart failure, cardiomyopathy, and myocarditis. We summarized the results of the studies, including meta-analyses and original investigations, and presented them according to the different forms of CVD. Meta-analyses published in 2015 provided mixed results regarding the relationship between CD and CVD. However, subsequent original investigations have shed new light on this association. Recent studies indicate that individuals with CD are at a higher risk of developing overall CVD, including an increased risk of myocardial infarction and atrial fibrillation. However, the link between CD and stroke is less established. Further research is needed to determine the link between CD and other cardiac arrhythmias, such as ventricular arrhythmia. Moreover, the relationship between CD and cardiomyopathy or heart failure, as well as myopericarditis, remains ambiguous. CD patients have a lower prevalence of traditional cardiac risk factors, such as smoking, hypertension, hyperlipidemia, and obesity. Therefore, it is important to discover strategies to identify patients at risk and reduce the risk of CVD in CD populations. Lastly, it is unclear whether adherence to a gluten-free diet can diminish or increase the risk of CVD among individuals with CD, necessitating further research in this area. To fully comprehend the correlation between CD and CVD and to determine the optimal prevention strategies for CVD in individuals with CD, additional research is necessary.

Dual antiplatelet therapy (DAPT) combines two antiplatelet agents to decrease the risk of thrombotic complications associated with atherosclerotic cardiovascular diseases. Emerging data about the duration of DAPT is being published continuously. New approaches are trying to balance the time, benefits, and risks for patients taking DAPT for established cardiovascular diseases. Short-term dual DAPT of 3-6 months, or even 1 month in high-bleeding risk patients, is equivalent in terms of efficacy and effectiveness compared to long-term DAPT for patients who experienced percutaneous coronary intervention in an acute coronary syndrome setting. Prolonged DAPT beyond 12 months reduces stent thrombosis, major adverse cardiovascular events, and myocardial infarction rates but increases bleeding risk. Extended DAPT does not significantly benefit stable coronary artery disease patients in reducing stroke, myocardial infarction, or cardiovascular death. Ticagrelor and aspirin reduce cardiovascular events in stable coronary artery disease with diabetes but carry a higher bleeding risk. Antiplatelet therapy duration in atrial fibrillation patients after percutaneous coronary intervention depends on individual characteristics and bleeding risk. Antiplatelet therapy is crucial for post-coronary artery bypass graft and transcatheter aortic valve implantation; Aspirin (ASA) monotherapy is preferred. Antiplatelet therapy duration in peripheral artery disease depends on the scenario. Adding vorapaxar and cilostazol may benefit secondary prevention and claudication, respectively. Carotid artery disease patients with transient ischemic attack or stroke benefit from antiplatelet therapy and combining ASA and clopidogrel is more effective than ASA alone. The optimal duration of DAPT after carotid artery stenting is uncertain. Resistance to ASA and clopidogrel poses an incremental risk of deleterious cardiovascular events and stroke. The selection and duration of antiplatelet therapy in patients with cardiovascular disease requires careful consideration of both efficacy and safety outcomes. The use of combination therapies may provide added benefits but should be weighed against the risk of bleeding. Further research and clinical trials are needed to optimize antiplatelet treatment in different patient populations and clinical scenarios.

Background: Inadequate sleep duration and poor sleep quality are associated with adverse cardiovascular outcomes. Methods: Using data from the National Health Interview Survey, we compared self-reported sleep duration and quality among different groups: Whites, Chinese, Asian Indian, Filipino, and Other Asians. Outcome included Sleep duration (≥7 and <7 hours) and sleep quality (coded as a binary variable). Results: We included 155,203 participants. The overall prevalence of ≥7 hours of sleep was 69.5% and poor sleep quality was reported by 73.9%. Compared to Whites and Chinese, Filipinos, and Other Asians were less likely to get adequate sleep (≥7 hours). All 4 Asian groups were less likely to report poor sleep quality compared with White individuals, while Asian Indians reported poor sleep quality less frequently compared with Chinese individuals. Conclusion: There are significant differences in sleep duration and quality between White and Asian groups, as well as within Asian subgroups. Further studies with disaggregated Asian subgroup data are needed to formally study these disparities.

Gastroesophageal reflux disease (GERD) is a very common disease with an estimated 442 million cases worldwide. It is a well-documented independent risk factor for many gastrointestinal pathologies, however, its role in cardiovascular disease (CVD) is unclear, despite its high prevalence in patients with CVD. Although traditionally considered a causative agent of noncardiac chest pain, a common imitator of cardiac chest pain, or an incidentally shared comorbidity in patients with CVD, a number of studies have implicated GERD and its therapies as risk factors for CVD. This narrative review will explore the relationship between GERD and CVD, including medical and mechanical therapeutic approaches for GERD that could potentially impact the incidence, progression, and mortality of CVD.

Artificial intelligence, specifically advanced language models such as ChatGPT, have the potential to revolutionize various aspects of healthcare, medical education, and research. In this review, we evaluate the myriad applications of artificial intelligence in diverse healthcare domains. We discuss its potential role in clinical decision-making, exploring how it can assist physicians by providing rapid, data-driven insights for diagnosis and treatment. We review the benefits of artificial intelligence such as ChatGPT in personalized patient care, particularly in geriatric care, medication management, weight loss and nutrition, and physical activity guidance. We further delve into its potential to enhance medical research, through the analysis of large datasets, and the development of novel methodologies. In the realm of medical education, we investigate the utility of artificial intelligence as an information retrieval tool and personalized learning resource for medical students and professionals.

Recent studies have shown that a pro-inflammatory diet and dysbiosis, especially a high level of trimethylamine-N-oxide (TMAO), are associated with various adverse health conditions. Cardiovascular diseases and pancreatic diseases are two major morbidities in the modern world. Through this narrative review, we aimed to summarize the association between a pro-inflammatory diet, gut microbiota, and cardiovascular and pancreatic diseases, along with their underlying mechanisms. Our review revealed that TMAO is associated with the development of cardiovascular diseases by promoting platelet aggregation, atherosclerotic plaque formation, and vascular inflammation. TMAO is also associated with the development of acute pancreatitis. The pro-inflammatory diet is associated with an increased risk of pancreatic cancer and cardiovascular diseases through mechanisms that include increasing TMAO levels, activating the lipopolysaccharides cascade, and the direct pro-inflammatory effect of certain nutrients. Meanwhile, an anti-inflammatory diet decreases the risk of cardiovascular diseases and pancreatic cancer.

Mesenteric ischemia is a challenging condition characterized by insufficient blood perfusion to the mesentery and, consequently, intestinal tissues that continues to perplex clinicians. Despite its low prevalence, the condition’s variable clinical presentation and elusive radiographic diagnosis can delay life-saving interventions in the acute setting and deteriorate the quality of life of patients when left undiagnosed or misdiagnosed. Purpose: Review and summarize recent diagnostic updates and emergent intervention strategies for acute and chronic mesenteric ischemia. Methods: A narrative review of all relevant studies from January 2022 through September 2023. Results: A total of 11 studies from MEDLINE, supplemented with 44 studies from Google Scholar, were included in the review. Conclusions: Both acute and chronic mesenteric ischemia propose diagnostic and therapeutic challenges for interventionalists. Computed tomographic angiography remains the diagnostic modality of choice for both. Open surgical intervention remains the gold standard for acute mesenteric ischemia, while endovascular techniques are preferred for chronic mesenteric ischemia.