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In this report from the Swedish Obese Subjects study, the rate of incident type 2 diabetes in usual-care and bariatric-surgery groups was 28.4 and 6.8 cases per 1000 person-years, respectively. These findings suggest that surgery is much more efficient than usual care. Multiple studies have shown associations between obesity and type 2 diabetes 1 – 6 and between changes in body weight and incident type 2 diabetes. 7 , 8 It is also well established that the worldwide increase in obesity is associated with an increase in the prevalence of type 2 diabetes. 9 Currently, 285 million people have type 2 diabetes, and this number is predicted to increase to 439 million by 2030. 10 Among persons in a prediabetic state, the incidence of type 2 diabetes is reduced by approximately 40 to 45% with effective lifestyle changes or drug treatment, 11 – 15 and the effects persist, in part, . . .

Imaging-defined atherosclerosis represents an intermediate phenotype of atherosclerotic cardiovascular disease (ASCVD). Genome-wide association studies (GWAS) on directly measured coronary plaques using coronary computed tomography angiography (CCTA) are scarce. In the so far largest population-based cohort with CCTA data, we performed a GWAS on coronary plaque burden as determined by the segment involvement score (SIS) in 24,811 European individuals. We identified 20 significant independent genetic markers for SIS, three of which were found in loci not implicated in ASCVD before. Further GWAS on coronary artery calcification showed similar results to that of SIS, whereas a GWAS on ultrasound-assessed carotid plaques identified both shared and non-shared loci with SIS. In two-sample Mendelian randomization studies using SIS-associated markers in UK Biobank and CARDIoGRAMplusC4D, one extra coronary segment with atherosclerosis corresponded to 1.8-fold increased odds of myocardial infarction. This GWAS data can aid future studies of causal pathways in ASCVD. Here the authors present a genome-wide study linking 20 genetic markers to coronary plaque burden, revealing differences in coronary and carotid atherosclerosis genetics. It also demonstrates and quantifies a causal link between coronary plaques and myocardial infarction.

BackgroundBoth Takotsubo syndrome (TS) and ST-elevation myocardial infarction (STEMI) are conditions characterised by the acute onset of left ventricular (LV) dysfunction. While LV thrombus is a known complication of LV dysfunction, its epidemiology in these two patient groups remains poorly understood.MethodsWe used data from the Stunning in Takotsubo versus Acute Myocardial Infarction (STAMI) study, which prospectively enrolled patients with TS and STEMI at Sahlgrenska University Hospital. Serial echocardiography was performed on admission and on days 1, 2, 3, 7, 14 and 30. Predictors of LV thrombus were identified using Cox regression analyses.Results314 patients were included; 68 with TS, 148 with anterior STEMI and 98 with non-anterior STEMI. Mean LV ejection fraction (LVEF) at admission was 39% (95% CI 35.8 to 42.2) in TS, 46.7% (95% CI 43.3 to 50.1) in anterior STEMI and 52.8% (95% CI 48.9 to 56.7) in non-anterior STEMI. LV thrombus occurred in 20 of 246 (8.1%) STEMI patients but in none of the TS patients. All but one LV thrombus was found in anterior STEMI. All LV thrombi in anterior STEMI were detected within 7 days, while the single non-anterior LV thrombus was found on day 30. All patients with LV thrombi received anticoagulation. Predictors of LV thrombus included lower LVEF and higher troponin levels.ConclusionsDespite more severe LV dysfunction in TS compared with STEMI, LV thrombus was exclusively found in STEMI patients. Almost all LV thrombi were found in anterior STEMI within the first week and showed a high-resolution rate at 30 days. Our findings highlight pathophysiological differences between these two conditions, warranting further investigation and implications for differing surveillance needs after TS and STEMI.

Background Patients with type 2 diabetes have an increased risk of death and cardiovascular events and people with diabetes or prediabetes have been found to have increased atherosclerotic burden in the coronary and carotid arteries. This study will estimate the cross-sectional prevalence of atherosclerosis in the coronary and carotid arteries in individuals with prediabetes and diabetes, compared with normoglycaemic individuals in a large population-based cohort. Methods The 30,154 study participants, 50–64 years, were categorized according to their fasting glycaemic status or self-reported data as normoglycaemic, prediabetes, and previously undetected or known diabetes. Prevalence of affected coronary artery segments, severity of stenosis and coronary artery calcium score (CACS) were determined by coronary computed tomography angiography. Total atherosclerotic burden was assessed in the 11 clinically most relevant segments using the Segment Involvement Score and as the presence of any coronary atherosclerosis. The presence of atherosclerotic plaque in the carotid arteries was determined by ultrasound examination. Results Study participants with prediabetes (n = 4804, 16.0%) or diabetes (n = 2282, 7.6%) had greater coronary artery plaque burden, more coronary stenosis and higher CACS than normoglycaemic participants (all, p < 0.01). Among male participants with diabetes 35.3% had CACS ≥ 100 compared to 16.1% among normoglycaemic participants. For women, the corresponding figures were 8.9% vs 6.1%. The prevalence of atherosclerosis in the coronary arteries was higher in participants with previously undetected diabetes than prediabetes, but lower than in patients with known diabetes. The prevalence of any plaque in the carotid arteries was higher in participants with prediabetes or diabetes than in normoglycaemic participants. Conclusions In this large population-based cohort of currently asymptomatic people, the atherosclerotic burden in the coronary and carotid arteries increased with increasing degree of dysglycaemia. The finding that the atherosclerotic burden in the coronary arteries in the undetected diabetes category was midway between the prediabetes category and patients with known diabetes may have implications for screening strategies and tailored prevention interventions for people with dysglycaemia in the future.

AimsWe investigated the prevalence of coronary microvascular dysfunction (CMD) and its association with severity of heart failure in patients with reduced or mildly reduced ejection fraction (HFrEF and HFmrEF).MethodPatients with stable, symptomatic heart failure with left ventricular ejection fraction (LVEF) <50% were enrolled. Data collection included physical examination, blood samples, Kansas City Cardiomyopathy Questionnaire (KCCQ), carotid to femoral pulse wave velocity, echocardiography and adenosine-based transthoracic Doppler echocardiography to assess coronary flow reserve (CFR). A CFR <2.5 was used to diagnose CMD. Adjusted multivariable linear regression analysis with CFR as the dependent variable and adjusted multivariate logistic regression with CMD as the dependent variable were performed.ResultsA total of 125 patients were included, of whom 99 (79%) were men. The overall mean age is 73.4 (±7.5) years. In patients eligible for CFR (n=68, 54%), CMD was present in 45 (66%). Patients with CMD had higher N-terminal pro B-type natriuretic peptide (NTproBNP), hsTroponin-T, lower KCCQ score, lower left and right ventricular and left atrial global longitudinal strain (GLS) (p<0.05). In multivariable linear regression, lower CFR was independently associated with reduced GLS, higher NTproBNP and hsTroponin-T. Furthermore, in adjusted logistic regression analysis, lower LVEF, reduced right ventricular GLS and higher biomarkers were independently associated with an increased risk of CMD.ConclusionCMD was present in 66% of patients with chronic heart failure and HFrEF or HFmrEF. Markers of more severe heart failure, including reduced GLS and higher NTproBNP and hsTroponin-T, were independently associated with lower CFR. Reduced right ventricular GLS and higher levels of the biomarkers were also independently associated with CMD.

Background Bilberries from Sweden, rich in polyphenols, have shown cholesterol-lowering effects in small studies, and the cholesterol-lowering properties of oats, with abundant beta-glucans and potentially bioactive phytochemicals, are well established. Both may provide cardiometabolic benefits following acute myocardial infarction (AMI), but large studies of adequate statistical power and appropriate duration are needed to confirm clinically relevant treatment effects. No previous study has evaluated the potential additive or synergistic effects of bilberry combined with oats on cardiometabolic risk factors. Our primary objective is to assess cardioprotective effects of diet supplementation with dried bilberry or with bioprocessed oat bran, with a secondary explorative objective of assessing their combination, compared with a neutral isocaloric reference supplement, initiated within 5 days following percutaneous coronary intervention (PCI) for AMI. Methods The effects of Bi lberry and O at intake on lipids, inflammation and exercise capacity after A cute M yocardial I nfarction (BIOAMI) trial is a double-blind, randomized, placebo-controlled clinical trial. A total of 900 patients will be randomized post-PCI to one of four dietary intervention arms. After randomization, subjects will receive beverages with bilberry powder (active), beverages with high-fiber bioprocessed oat bran (active), beverages with bilberry and oats combined (active), or reference beverages containing no active bilberry or active oats, for consumption twice daily during a 3-month intervention. The primary endpoint is the difference in LDL cholesterol change between the intervention groups after 3 months. The major secondary endpoint is exercise capacity at 3 months. Other secondary endpoints include plasma concentrations of biochemical markers of inflammation, metabolomics, and gut microbiota composition after 3 months. Discussion Controlling hyperlipidemia and inflammation is critical to preventing new cardiovascular events, but novel pharmacological treatments for these conditions are expensive and associated with negative side effects. If bilberry and/or oat, in addition to standard medical therapy, can lower LDL cholesterol and inflammation more than standard therapy alone, this could be a cost-effective and safe dietary strategy for secondary prevention after AMI. Trial registration ClinicalTrials.gov NCT03620266 . Registered on August 8, 2018.

PurposeWe examined whether end-to-end deep-learning models could detect moderate (≥50%) or severe (≥70%) stenosis in the left anterior descending artery (LAD), right coronary artery (RCA) or left circumflex artery (LCX) in iodine contrast-enhanced ECG-gated coronary CT angiography (CCTA) scans.MethodsFrom a database of 6293 CCTA scans, we used pre-existing curved multiplanar reformations (CMR) images of the LAD, RCA and LCX arteries to create end-to-end deep-learning models for the detection of moderate or severe stenoses. We preprocessed the images by exploiting domain knowledge and employed a transfer learning approach using EfficientNet, ResNet, DenseNet and Inception-ResNet, with a class-weighted strategy optimised through cross-validation. Heatmaps were generated to indicate critical areas identified by the models, aiding clinicians in understanding the model’s decision-making process.ResultsAmong the 900 CMR cases, 279 involved the LAD artery, 259 the RCA artery and 253 the LCX artery. EfficientNet models outperformed others, with EfficientNetB3 and EfficientNetB0 demonstrating the highest accuracy for LAD, EfficientNetB2 for RCA and EfficientNetB0 for LCX. The area under the curve for receiver operating characteristic (AUROC) reached 0.95 for moderate and 0.94 for severe stenosis in the LAD. For the RCA, the AUROC was 0.92 for both moderate and severe stenosis detection. The LCX achieved an AUROC of 0.88 for the detection of moderate stenoses, though the calibration curve exhibited significant overestimation. Calibration curves matched probabilities for the LAD but showed discrepancies for the RCA. Heatmap visualisations confirmed the models’ precision in delineating stenotic lesions. Decision curve analysis and net reclassification index assessments reinforced the efficacy of EfficientNet models, confirming their superior diagnostic capabilities.ConclusionOur end-to-end deep-learning model demonstrates, for the LAD artery, excellent discriminatory ability and calibration during internal validation, despite a small dataset used to train the network. The model reliably produces precise, highly interpretable images.

Premature coronary artery disease (CAD) is a major cause of mortality and morbidity. Increased low-density lipoprotein-cholesterol (LDL-C) level is a major risk factor for CAD and thus the main target for its prevention. Familial Hypercholesterolemia (FH) is a genetic inherited disorder characterized by high LDL-C, and subsequent premature CAD development. Early drug treatment with lipid-lowering medications in FH prevents cardiovascular disease onset. The FH prevalence in the Northern European general population is 0.3%, and it is estimated that it explains 20% of premature CAD cases in individuals with familial clustering. Despite the wide number of papers showing the prevalence of clinical FH in cardiovascular disease, the prevalence of genetic FH in individuals with premature CAD is not yet well known. Here, we examined the prevalence of genetically determined FH in individuals with premature CAD. 66 patients who underwent coronary angiography with suspected premature acute coronary syndrome (age <50 years for men and <55 years for women) underwent genetic screening to identify FH-causing mutations. All patients underwent physical and clinical examinations. Information about family and personal history, drug therapy and habits were also collected. We found FH-causative mutations in 3/66 (4.5%) screened individuals with premature CAD. When considering individuals with confirmed CAD after coronary angiography, the FH mutation prevalence was 6.1% (3/49). After excluding individuals with classical risk factors for CAD other than hypercholesterolemia, the FH mutation prevalence raised to 15.8% (3/19). In conclusion, we found that individuals with premature CAD have a more than 15-fold increased prevalence of FH mutations compared to the general population.

Hepatic steatosis in HCV patients has been postulated as a risk factor associated with a higher frequency of fibrosis and cirrhosis. A single genetic variant, PNPLA3 I148M, has been widely associated with increased hepatic steatosis. Previous studies of the PNPLA3 I148M sequence variant in HCV infected individuals have reported an association between this variant and prevalence of steatosis, fibrosis, and cirrhosis. To evaluate the impact of PNPLA3 I148M variant on metabolic traits and treatment response in HCV genotype 2 and 3 infected patients. Three hundred and eighty-two treatment naïve HCV genotype 2 or 3 infected patients were included in a phase III, open label, randomized, multicenter, investigator-initiated trial (the NORDynamIC study), in which pretreatment liver biopsies were mandatory. PNPLA3I148M genotyping was performed in a total of 359 Caucasian patients. In HCV genotype 2 infected patients carrying the PNPLA3 148M allele, there was significantly increased insulin resistance (P = 0.023) and lower viral load (P = 0.005) at baseline as well as the first seven days of antiviral treatment. These results were not observed in HCV genotype 3 infected patients. Our results suggest a possible association between the PNPLA3 148M allele and insulin resistance as well as baseline viral load in HCV genotype 2, but not in genotype 3.

Obese individuals with type 2 diabetes have an increased risk of cardiovascular disease. The effect of bariatric surgery on cardiovascular events in obese individuals with type 2 diabetes remains to be determined. The Swedish Obese Subjects (SOS) study is a prospective, controlled intervention study that examines the effects of bariatric surgery on hard end points. The aim of the present study was to examine the effect of bariatric surgery on cardiovascular events in the SOS study participants with type 2 diabetes. All SOS study participants with type 2 diabetes at baseline were included in the analyses (n = 345 in the surgery group and n = 262 in the control group). Mean follow-up was 13.3 years (interquartile range 10.2-16.4) for all cardiovascular events. Bariatric surgery was associated with a reduced myocardial infarction incidence (38 events among the 345 subjects in the surgery group vs. 43 events among the 262 subjects in the control group; log-rank P = 0.017; adjusted hazard ratio [HR] 0.56 [95% CI 0.34-0.93]; P = 0.025). No effect of bariatric surgery was observed on stroke incidence (34 events among the 345 subjects in the surgery group vs. 24 events among the 262 subjects in the control group; log-rank P = 0.852; adjusted HR 0.73 [0.41-1.30]; P = 0.29). The effect of surgery in reducing myocardial infarction incidence was stronger in individuals with higher serum total cholesterol and triglycerides at baseline (interaction P value = 0.02 for both traits). BMI (interaction P value = 0.12) was not related to the surgery outcome. Bariatric surgery reduces the incidence of myocardial infarction in obese individuals with type 2 diabetes. Preoperative BMI should be integrated with metabolic parameters to maximize the benefits of bariatric surgery.