Special Issue of JACC Examines Public Health Impact of CVD and Its Prevention

A special issue of the Journal of the American College of Cardiology (JACC), published May 28, focuses on the promotion of cardiovascular health, including issues that broadly impact public health and the prevention of cardiovascular disease and related conditions.

In the special issue's state-of-the-art review, David J.A. Jenkins, MD, PHD, DSC, et al., discuss supplemental vitamins and minerals for cardiovascular disease prevention and treatment, concluding that the current data on supplement use reinforce advice to focus on healthy dietary patterns, with an increased proportion of plant foods in which many required vitamins and minerals can be found. In another review article, Travis P. Baggett, MD, MPH, et al., explain that cardiovascular disease is a major cause of death among homeless adults, at rates that exceed those in non-homeless individuals. "Homeless people experience stark disparities in cardiovascular mortality, likely rooted in a unique profile of traditional and nontraditional risk factors combined with difficulties accessing care and adhering to evidence-based treatment," the authors write. "We suggest practical, patient-centered strategies for delivering preventive and therapeutic cardiovascular care to this vulnerable population."

Other highlights from the special issue include:

SGLT-2 Inhibitors and Cardiovascular Risk: Initiation of SGLT-2i may be associated with lower risk of death and heart failure (HF) regardless of pre-existing cardiovascular disease, according to a multinational, observational study led by Matthew A. Cavender, MD, MPH, FACC, et al. Using data from the CVD-REAL study in which adults with type 2 diabetes were identified, researchers examined patients prescribed an SGLT-2i or other glucose-lowering drugs and matched them based on a propensity score for initiation of an SGLT-2i. The results showed that compared with therapy using other glucose-lowering drugs, initiation of an SGLT-2i was associated with lower risk of death in patients with and without cardiovascular disease. There were also associations found between SGLT-2i and lower risk of HF and the composite of HF or death observed in patients with and without established cardiovascular disease. In an accompanying editorial comment, Michael E. Farkouh, MD, MSc, FACC, and Subodh Verma, MD, PhD, note that this study "continues to remind us of the importance of HF prevention in individuals with diabetes, while ushering hope that SGLT-2i may be a preferred agent of choice in the prevention of one of the deadliest complications of diabetes." They add, "whether SGLT-2i will be useful agents in the treatment (vs. prevention) of HF with and without diabetes remains an important question for which ongoing studies are currently underway."

Coronary Atherosclerotic Precursors of Acute Coronary Syndromes (ACS): High-risk plaque characteristics, plaque composition and cross-sectional plaque burden as assessed by coronary computed tomography angiography (CTA) may be able to predict the development of ACS independently of stenosis severity and aggregate plaque burden, according to a multicenter, case-control study led by Hyuk-Jae Chang, MD, PhD, et al. Using a nested case-control study within a cohort of 25,251 patients undergoing coronary CTA, the researchers matched patients with ACS and non-ACS patients with no prior coronary artery disease (CAD) for risk factors and coronary CTA-evaluated obstructive CAD. The results showed that more than 65 percent of patients with ACS had nonobstructive CAD at baseline and 52 percent had high-risk plaque. The diameter stenosis, cross-sectional plaque burden, fibrofatty and necrotic core volume, and high-risk plaque also increased the adjusted hazard ratio of ACS. In an accompanying editorial comment, James A. Goldstein, MD, FACC, notes that these observations support and further the promise of noninvasive identification of patients and plaques at risk. He adds, "these findings have potential implications for characterizing at-risk patients who may benefit from systemic therapeutics designed to stabilize the atherosclerotic coronary vasculature."

Short-Term Global Cardiovascular Disease Risk Prediction in Older Adults: The addition of biomarkers to the Pooled Cohort Equation (PCE) or use of a simpler lab model markedly improved short-term cardiovascular disease risk prediction, according to a study led by Anum Saeed, MD, et al. The researchers evaluated whether adding biomarkers to the PCE would enhance risk prediction in older adults over 79-years-old over a shorter time frame using three tools: PCE alone; PCE plus N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT) and high-sensitivity C-reactive protein (hs-CRP); and a lab model that included biomarkers, age, race and sex. Results showed that over a median follow-up of approximately four years, incident heart failure was the most common cardiovascular event, followed by coronary heart disease and stroke events. NT-proBNP and hs-cTnT each were significantly associated with incident global cardiovascular disease, atherosclerotic cardiovascular disease, coronary heart disease, stroke and heart failure, while hs-CRP was significantly associated with all but stroke. In an accompanying editorial comment, Jennifer G. Robinson, MD, MPH, et al., note that "the observation that adding biomarkers of myocardial injury, heart failure, and inflammation improved 4-year cardiovascular risk prediction in older adults is an important advance toward better individualizing prevention efforts in older adults." However, they add, "validation in other populations is needed before these equations are implemented in clinical practice."

Cocaine and Marijuana Use: Cocaine or marijuana use was associated with worse all-cause and cardiovascular mortality among patients younger than 50 years who experienced a myocardial infarction (MI), according to findings from the Partners YOUNG-MI study led by Ersilia M. DeFilippis, MD, et al. Using the retrospective registry study, the researchers assessed the prevalence of cocaine and marijuana use and its association with outcomes in 2,097 patients presenting with their first MI under 50 years of age. Results showed that a significantly higher percentage of STEMIs occurred in the substance use group vs. the nonsubstance use group and out-of-hospital cardiac arrest occurred significantly more often in patients with substance use vs. those without. Additionally, patients with substance use had significantly higher all-cause mortality vs. those without during a median follow-up of 11.2 years. In an accompanying editorial comment, Joshua D. Lee, MD, MSc, et al., note that this study "is a timely reminder of how little we know about cannabis consumption, cardiovascular disease and cannabis' health effects in general." They add, "We encourage increasing collaboration among cardiologists and drug use and addiction experts to further advance our understanding of the potential health consequences of increased cannabis use in the U.S."

Sex Hormones and Heart Disease Risk in Post-Menopausal Women: In post-menopausal women, having a higher blood level of a male hormone (testosterone) and a higher ratio of the male-type to female-type (estrogen) of hormones is associated with a higher risk of heart disease later in life, according to a study led by Di Zhao, PHD, et al. Using data from the Multi-Ethnic Study of Atherosclerosis, researchers evaluated the association of sex hormone levels with incident cardiovascular disease, coronary heart disease and heart failure over a 12-year follow-up in 2,834 postmenopausal women free of cardiovascular disease at baseline. Results showed a higher testosterone to estradiol ratio was associated with an elevated risk for incident cardiovascular disease, coronary heart disease and heart failure. Additionally, higher total testosterone was associated with an increased risk for coronary heart disease and total cardiovascular disease, while higher estradiol levels were associated with a lower risk of coronary heart disease. In an accompanying editorial comment, Virginia M. Miller, PhD, notes that while this study provides new insight into relationships and endogenous hormones and cardiovascular events, more research is needed to better understand the "complex hormonal environment affecting cellular and organ functions involved in the development and progression of cardiovascular disease in women as they age."

Read the full JACC Cardiovascular Health Promotion issue.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, ACS and Cardiac Biomarkers, Anticoagulation Management and ACS, SCD/Ventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Smoking

Keywords: Cannabis, Marijuana Smoking, Case-Control Studies, Natriuretic Peptide, Brain, Estradiol, C-Reactive Protein, Risk Factors, Postmenopause, Troponin T, Cross-Sectional Studies, Retrospective Studies, Diabetes Mellitus, Type 2, Acute Coronary Syndrome, Testosterone, Propensity Score, Prevalence, Cocaine, Out-of-Hospital Cardiac Arrest, Glucose, Constriction, Pathologic, Vulnerable Populations, Cause of Death, Follow-Up Studies, Coronary Vessels, Heart Failure, Myocardial Infarction, Coronary Disease, Peptide Fragments, Stroke, Atherosclerosis, Estrogens, Registries, Inflammation, Health Promotion, Minerals, Diabetes Complications, Vitamins

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