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Patients with known cardiovascular disease who have not had a recent acute event are often referred to as having stable coronary artery disease (CAD). The concept of ‘stable’ CAD is misleading for two important reasons: the continuing risks of cardiovascular events over the longer term and the diverse spectrum of powerful risk characteristics. The risks of cardiovascular events are frequently underestimated and continue to exist, despite current standards of care for secondary prevention, including lifestyle changes, optimal medical therapy, myocardial revascularization and the use of antiplatelet agents to limit thrombosis. In dispelling the myth of ‘stable’ CAD, we explore the pathophysiology of the disease and the relative contribution of plaque and systemic factors to cardiovascular events. A broader concept of the vulnerable patient, not just the vulnerable plaque, takes into account the diversity and future risks of atherothrombotic events. We also evaluate new and ongoing research into medical therapies aimed at further reducing the risks of cardiovascular events in patients with chronic — but not stable — atherothrombotic disease.

Climate change threatens human health and general welfare via multiple dimensions. However, the associations of short-term exposure to temperature variability, a crucial aspect of climate change, with myocardial infarction (MI) hospital admissions remains unclear. This population-based nationwide study employed a time-stratified, case-crossover design to investigate the association between ambient temperature variability and MI hospital admissions among 233,617 patients recorded in the SWEDEHEART registry in Sweden between 2005 and 2019. High-resolution (1 × 1 km) daily mean ambient temperature was assigned to patients' residential areas. Temperature variability was calculated as the difference between the same-day (as the MI event) ambient temperature and the average temperature over the preceding 7 days. An upward temperature shift represents a rise in the current day's temperature relative to the 7-day average, while a downward temperature shift indicates a corresponding decrease. A conditional logistic regression model with distributed lag non-linear model was applied to estimate the association between ambient temperature variability and total MI (encompassing all MI types), ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) hospital admissions at lag 0-6 days. Potential effect modifiers, such as sex, history of diseases, and season, were also examined. The patients had an average age of 70.6 years, and 34.5% of them were female. Our study found that an upward temperature shift was associated with increased risks of total MI (encompassing all MI types), STEMI, and NSTEMI hospital admissions at lag 0 day, with odds ratios (OR, 95% confidence intervals [CIs]) of 1.009 (1.005, 1.013; p < 0.001), 1.014 (1.006, 1.022; p < 0.001), and 1.007 (1.001, 1.012; p = 0.014) per 1 °C increase, respectively. These associations attenuated and became non-significant over lags 1-6 days. Furthermore, a downward temperature shift was associated with increased risks of hospital admissions for total MI (encompassing all MI types) at a lag of 2 days with an OR (95% CI): 1.003 (1.001, 1.005; p = 0.014), and for STEMI at lags 2 and 3 days with ORs (95% CI): 1.006 (1.002, 1.010; p = 0.001) and 1.005 (1.001, 1.008; p = 0.011), per 1 °C decrease, respectively. Conversely, higher downward temperature shifts were associated with decreased risks of total MI (encompassing all MI types) and NSTEMI at lag 0 day. No significant associations were observed at other lag days for downward temperature shifts. Males and patients with diabetes had higher MI hospitalization risks from upward temperature shift exposure, while downward temperature shift exposure in cold seasons posed greater MI hospitalization risks. A methodological limitation was the use of ambient temperature variability as a proxy for personal exposure, which, while practical for large-scale studies, may not precisely reflect individual temperature exposure. This nationwide study contributes insights that short-term exposures to higher temperature variability-greater upward or downward temperature shifts-are associated with an increased risk of MI hospitalization. Our finding highlights the cardiovascular health threats posed by higher temperature variability, which are anticipated to increase in frequency and intensity due to climate change.

The effects of β-blocker therapy on clinical outcomes in patients with myocardial infarction and mildly reduced (40–49%) left ventricular ejection fraction (LVEF) are largely unknown. Four recently conducted randomised trials tested the efficacy of β blockers after a recent myocardial infarction in patients without reduced LVEF (LVEF ≥40%). However, none were individually powered to assess these effects in the subgroup of patients with mildly reduced LVEF. We aimed to assess the efficacy of β blockers in patients with myocardial infarction and mildly reduced LVEF during the index hospitalisation. We conducted an individual patient-level meta-analysis of patients with mildly reduced LVEF and no history or signs of heart failure from four recent clinical trials. These studies were included because they were randomised controlled trials testing long-term effects (median follow-up >1 year) of oral β-blocker therapy in patients who recently had a myocardial infarction (randomisation within 14 days) and had mildly reduced LVEF. No further studies were found in a systematic review (Jan 1, 2020 to June 26, 2025). A one-stage, fixed-effects, Cox proportional hazards regression model was used to assess the treatment effect of β blockers on the predefined primary composite endpoint of all-cause death, new myocardial infarction, or heart failure. All endpoints were independently adjudicated. This meta-analysis was registered with PROSPERO (CRD420251023480). 1885 patients with myocardial infarction and mildly reduced LVEF were included in the meta-analysis: 979 from the REBOOT trial, 422 from the BETAMI trial, 430 from the DANBLOCK trial, and 54 from the CAPITAL-RCT trial. Overall, 991 patients were assigned to β blockers and 894 to control (no β blockers). The primary composite endpoint occurred in 106 patients (32·6 events per 1000 patient-years) in the β-blocker group and 129 patients (43·0 per 1000 patient-years) in the no β-blocker group (hazard ratio 0·75 [95% CI 0·58–0·97]; p=0·031). No heterogeneity between the trials (trial-by-treatment pinteraction=0·95) or between countries of enrolment was observed (pinteraction=0·98). In patients with acute myocardial infarction with mildly reduced LVEF without history or clinical signs of heart failure, β-blocker therapy was associated with a reduction in the composite of all-cause death, new myocardial infarction, or heart failure. These results extend the known benefits of these agents in patients with myocardial infarction with reduced LVEF to the subgroup with mildly reduced LVEF. Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Danish Heart Foundation, Novo Nordisk Foundation, South-Eastern Norway Regional Health Authority, and Research Council of Norway.

The objective of the study was to investigate variability and agreement of the commonly used image processing method “n-SD from remote” and in particular for quantifying myocardial infarction by late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR). LGE-CMR in tandem with the analysis method “n-SD from remote” represents the current reference standard for infarct quantification. This analytic method utilizes regions of interest (ROIs) and defines infarct as the tissue with a set number of standard deviations (SD) above the signal intensity of remote nulled myocardium. There is no consensus on what the set number of SD is supposed to be. Little is known about how size and location of ROIs and underlying signal properties in the LGE images affect results. Furthermore, the method is frequently used elsewhere in medical imaging often without careful validation. Therefore, the usage of the “n-SD” method warrants a thorough validation. Data from 214 patients from two multi-center cardioprotection trials were included. Infarct size from different remote ROI positions, ROI size, and number of standard deviations (“n-SD” ) were compared with reference core lab delineations. Variability in infarct size caused by varying ROI position, ROI size, and “n-SD” was 47%, 48%, and 40%, respectively. The agreement between the “n-SD from remote” method and the reference infarct size by core lab delineations was low. Optimal “n-SD” threshold computed on a slice-by-slice basis showed high variability, n = 5.3 ± 2.2. The “n-SD from remote” method is unreliable for infarct quantification due to high variability which depends on different placement and size of remote ROI, number “n-SD” , and image signal properties related to the CMR-scanner and sequence used. Therefore, the “n-SD from remote” method should not be used, instead methods validated against an independent standard are recommended.

Background For healthcare workers, working through a pandemic may include both challenges, such as coping with increased demands and a lack of control, and rewards, such as experiencing a sense of achievement and meaningfulness. In this study, we explore the accomplishments healthcare workers themselves are proud of achieving at work, in order to elucidate the positive aspects of working through a pandemic. Methods In June 2020 (T1), December 2020 (T2), and May 2021 (T3), healthcare workers (n = 1,996) at four Norwegian hospitals participated in a web-based survey assessing job strain, psychological health, and support during the pandemic. The survey included the open-ended question “During the past two weeks, what have you been feeling proud of achieving at work?” . Responses (1,046) to this item were analyzed using conventional content analysis, which resulted in 13 subthemes under 6 themes. Results For some, pride was found in their professional identity and dedication to their work. Others took pride in specific achievements, such as juggling their own needs (e.g., health, private life) with those of the workplace, contributing to cohesion and collaboration, their ability to learn and adjust, in being a useful resource at work, and in their efforts towards developing the organization and workplace. Implications The current findings shed light on what healthcare workers feel proud of achieving in their day-to-day work. Assessment of these factors provides insight on both positive and negative aspects of working clinically during a pandemic, and highlights specific targets for building sustainable and rewarding work environments for healthcare workers.

APOE encodes a cholesterol transporter, and the ε4 allele is associated with higher circulating cholesterol levels, ß-amyloid burden, and risk of Alzheimer’s disease. Prior studies demonstrated no significant differences in objective or subjective cognitive function for patients receiving the PCSK9 inhibitor evolocumab vs. placebo added to statin therapy. There is some evidence that cholesterol-lowering medications may confer greater cognitive benefits in APOE ε4 carriers. Thus, the purpose of this study was to determine whether APOE genotype moderates the relationships between evolocumab use and cognitive function. APOE -genotyped patients (N = 13,481; 28% ε4 carriers) from FOURIER, a randomized, placebo-controlled trial of evolocumab added to statin therapy in patients with stable atherosclerotic cardiovascular disease followed for a median of 2.2 years, completed the Everyday Cognition Scale (ECog) to self-report cognitive changes from the end of the trial compared to its beginning; a subset (N = 835) underwent objective cognitive testing using the Cambridge Neuropsychological Test Automated Battery as part of the EBBINGHAUS trial. There was a dose-dependent relationship between APOE ε4 genotype and patient-reported memory decline on the ECog in the placebo arm ( p = .003 for trend across genotypes; ε4/ε4 carriers vs. non-carriers: OR = 1.46, 95% CI [1.03, 2.08]) but not in the evolocumab arm ( p = .50, OR = 1.18, 95% CI [.83,1.66]). However, the genotype by treatment interaction was not significant ( p = .30). In the subset of participants who underwent objective cognitive testing with the CANTAB, APOE genotype did not significantly modify the relationship between treatment arm and CANTAB performance after adjustment for demographic and medical covariates, ( p ’s>.05). Although analyses were limited by the low population frequency of the ε4/ε4 genotype, this supports the cognitive safety of evolocumab among ε4 carriers, guiding future research on possible benefits of cholesterol-lowering medications in people at genetic risk for Alzheimer’s disease.

Background While several cross-sectional studies have suggested high burnout levels among health-care workers (HCW) during the Covid-19 pandemic, fewer studies have examined longitudinal trajectories of burnout. Objectives To examine (1) trajectories of change in levels of burnout among Norwegian HCW during a one-year period in the mid-phase of the Covid-19 pandemic (second, third, and fourth incidence rate peaks), and (2) how demographic and occupational variables, and pandemic-related experiences (e.g., own infection, severe infection in family, friend, or colleague, caring for deceased patient with Covid-19) were associated with such change. Methods Burnout was measured by the Copenhagen Burnout Inventory. Latent growth curve modeling was used to estimate trajectories of burnout symptoms, and predictors of starting point and rate of change in burnout levels. Results Starting points of burnout scores were, on average, low-to-moderate. Women, younger HCW, those living alone, and nurses had higher initial scores. Overall, burnout scores remained mostly unchanged across the study period. However, lower burnout scores at the initial assessment were associated with increasing scores over time. Being exposed to patients with Covid-19 and having a Covid-19 infection were associated with increased burnout over time. Conclusions While burnout symptoms among frontline health workers remained stable across the peaks of the Covid-19 pandemic overall, the study identified higher risk of worsening symptoms over time among certain demographic (younger personnel, females, and nurses) and highly exposed individuals and groups. These findings may be helpful for identifying frontline workers at particular risk of burnout during future public health emergencies.

Aims Hospital admissions of patients with chest pain considered as low risk for acute coronary syndrome contribute to increased costs and crowding in the emergency departments. This study aims to estimate the cost-effectiveness of assessing these patients in a primary care emergency setting, using the European Society of Cardiology (ESC) 0/1-h algorithm for high-sensitivity cardiac troponin T, compared to routine hospital management. Methods A cost-effectiveness analysis was conducted. For the primary care estimates, costs and health care expenditure from the observational OUT-ACS (One-hoUr Troponin in a low-prevalence population of Acute Coronary Syndrome) study were compared with anonymous extracted administrative data on low-risk patients at a large general hospital in Norway. Patients discharged home after the hs-cTnT assessment were defined as low risk in the primary care cohort. In the hospital setting, the low-risk group comprised patients discharged with a non-specific chest pain diagnosis (ICD-10 codes R07.4 and Z03.5). Loss of health related to a potential increase in acute myocardial infarctions the following 30-days was estimated. The primary outcome measure was the costs per quality-adjusted life year (QALY) of applying the ESC 0/1-h algorithm in primary care. The secondary outcomes were health care costs and length of stay in the two settings. Results Differences in costs comprise personnel and laboratory costs of applying the algorithm at primary care level (€192) and expenses related to ambulance transports and complete hospital costs for low-risk patients admitted to hospital (€1986). Additional diagnostic procedures were performed in 31.9% (181/567) of the low-risk hospital cohort. The estimated reduction in health care cost when using the 0/1-h algorithm outside of hospital was €1794 per low-risk patient, with a mean decrease in length of stay of 18.9 h. These numbers result in an average per-person QALY gain of 0.0005. Increased QALY and decreased costs indicate that the primary care approach is clearly cost-effective. Conclusion Using the ESC 0/1-h algorithm in low-risk patients in emergency primary care appears to be cost-effective compared to standard hospital management, with an extensive reduction in costs and length of stay per patient.

The earth's climate is changing and increasing ambient heat levels are emerging in large areas of the world. An important cause of this change is the anthropogenic emission of greenhouse gases. Climate changes have a variety of negative effects on health, including cardiac health. People with pre-existing medical conditions such as cardiovascular disease (including heart failure), people carrying out physically demanding work and the elderly are particularly vulnerable. This review evaluates the evidence base for the cardiac health consequences of climate conditions, with particular reference to increasing heat exposure, and it also explores the potential further implications.

Cardiovascular magnetic resonance (CMR) can accurately measure left ventricular (LV) mass, and several measures related to LV wall thickness exist. We hypothesized that prognosis can be used to select an optimal measure of wall thickness for characterizing LV hypertrophy. Subjects having undergone CMR were studied (cardiac patients, n = 2543; healthy volunteers, n = 100). A new measure, global wall thickness (GT, GTI if indexed to body surface area) was accurately calculated from LV mass and end-diastolic volume. Among patients with follow-up (n = 1575, median follow-up 5.4 years), the most predictive measure of death or hospitalization for heart failure was LV mass index (LVMI) (hazard ratio (HR)[95% confidence interval] 1.16[1.12–1.20], p < 0.001), followed by GTI (HR 1.14[1.09–1.19], p < 0.001). Among patients with normal findings (n = 326, median follow-up 5.8 years), the most predictive measure was GT (HR 1.62[1.35–1.94], p < 0.001). GT and LVMI could characterize patients as having a normal LV mass and wall thickness, concentric remodeling, concentric hypertrophy, or eccentric hypertrophy, and the three abnormal groups had worse prognosis than the normal group (p < 0.05 for all). LV mass is highly prognostic when mass is elevated, but GT is easily and accurately calculated, and adds value and discrimination amongst those with normal LV mass (early disease).