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29th September 2021
World Heart Day (WHD) was created by the World Heart Federation in 2000 and since that time, 29th September has been designated annual WHD. The purpose of WHD is to inform people across the globe of the simple fact that cardiovascular disease (CVD), remains the world’s leading cause of death. According to figures produced by the World Health Organisation, in 2020, CVD resulted in an estimated 17.9 million deaths. Perhaps the most disheartening aspect of this enormous death toll, is that 80 per cent of premature heart disease and stroke is preventable. While the theme of the 2021 WHD is “heart to connect”, i.e., harnessing the power of digital health to improve awareness, prevention and management of CVD globally, what is the evidence for the impact of digital health on cardiovascular disease outcomes?
Digital innovations in cardiology
The term “digital health” encompasses a number of technologies including electronic and mobile health platforms (eHealth and mHealth), telemedicine, wearable devices, sensors and artificial intelligence (AI). The European Society of Cardiology, has a section on its website looking at digital health in action, with a number of examples of how technologies are being used to support both clinicians and patients.
Taken together, each of these innovations is designed to improve both access to and delivery of, healthcare. There are already many examples of the value of digital technologies in cardiology, for instance, in the provision of health education, tele-rehabilitation as well as for disease prediction (e.g., AI systems) and even vital sign monitoring as witnessed by improvements in wearable devices.
Cardiovascular medicine it seems, has embraced digital health innovations for many years as demonstrated in a 2015 systematic review and meta-analysis. The review included 51 studies and assessed the impact of digital innovations on cardiovascular outcomes such as CVD events, all-cause mortality compared to control groups without such interventions. Overall, there was a 39% reduction in CVD outcomes accompanied by reductions in weight and body mass index, compared to controls. Additionally, a 2019 review, found that heart failure and stroke were the two most common cardiovascular conditions that were managed with digital health interventions. Perhaps most important, was the conclusion in which the authors stated that “the majority of the studies were good quality cost-effectiveness analyses with an adequate duration of time frame” and that “all the included studies found the DHIs [digital health interventions] to be cost-effective.”
Despite these promising developments, one major barrier that remains, is changing modifiable cardiovascular lifestyle factors such as smoking, reducing alcohol intake and increased levels of physical exercise. Nevertheless, it seems that digital health may also be part of the solution. In a review of studies with digital technology such as mobile phones, the internet, smartphone apps and wearables, the authors found that these innovations may improve some modifiable lifestyle measures such as healthy eating and greater levels of physical activity and that interventions were certainly more effective when used in combination.
Perhaps one of the biggest drivers for the incorporation of digital health in medicine as a whole, has been the current COVID-19 pandemic. With many countries forced to impose many national lockdowns, healthcare systems had to quickly evolve and adopt digital measures to maintain some level of services. Moving forward, digital health should now be perceived as part of the new normal for cardiovascular services and which hopefully should allow for the successful implementation of the aspirations of World Heart Day 2021.
27th September 2021
Cardiovascular diseases (CVDs) cause an estimated 17.9 million deaths every year and globally, account for 32% of all mortalities. Reduced intake of fats, and in particular, saturated fats, has become a central recommendation for many years. For example, the NHS suggests that men should eat no more than 30g per day of saturated fat. In fact, reducing intake of saturated fat has been suggested as a means of reducing cardiovascular events, especially if the fat is replaced with unsaturated fats. However, in recent years, meta-analyses of randomised trials and observational studies found no beneficial effects of reducing saturated fat intake intake on cardiovascular disease (CVD) and total mortality, and instead found protective effects against stroke. Although studies linking fact intake and cardiovascular disease have often relied upon self-reported intake, these can be unreliable. This led an international team of researchers, led by The George Institute for Global Health, University of New South Wales, Australia, to investigate the association between serum levels of pentadecanoic acid (15:0), a biomarker for dairy fat intake and both incident cardiovascular disease (CVD) and all-cause mortality in a Swedish Cohort. The 15:0 was measured at baseline together with a series of questionnaires, between 1997 and 1999 and follow-up information was collected until December 2014. The primary outcomes of interest were incident CVD and all-cause mortality which were obtained from death registries and reported as hazard ratios. In addition, the authors included the results of their study in a systematic review and meta-analysis with a number of other studies.
The study included 4,150 adults with a mean age of 60.5 years (51% female) at baseline and who were followed for a median of 16.6 years. During this time there were 578 incident CVD events and 676 deaths (198 due to CVD). Higher serum 15:0 levels were associated with a lower incident CVD (hazard ratio, HR = 0.75, 95% CI 0.61 – 0.93, p = 0.009). However, there was no significant association of 15:0 serum levels with all-cause mortality (p = 0.38).
In the meta-analysis which included 18 studies and 42,736 participants, comparing the highest to lowest serum 15:0 levels, was associated with a 12% reduction in CVD (HR = 0.88, 95% CI 0.78 – 0.99) but as with the single study, there was no association with all-cause mortality.
The authors concluded that higher levels of 15:0, which are related to an increased intake of dairy fats, was associated with a lower risk of incident CVD and that these findings were supported by the meta-analysis. They called for further studies to ascertain the causality of this relationship and the potential role of dairy foods in CVD prevention.
21st September 2021
Regular intake of nuts has been associated with a 15% lower risk of cardiovascular disease and a 23% lower risk of cardiovascular mortality. This reduction in risk is probably due to a reduction in low-density cholesterol (LDL-C) levels with one pooled analysis of 25 intervention trials finding that a mean daily intake of 67g of nuts produced a 7.4% mean reduction in LDL-C levels. However, none of the 25 trials lasted longer than 8 weeks and have not examined the effect of nuts on different LDL sub-fractions. In trying to establish the effect of both daily nut consumption and any differences in the effect on low-density lipoprotein levels, a team from the Lipid Clinic, Endocrinology and Nutrition Services, Villarroel, Barcelona, Spain, decided to explore these effects in a randomised trial. The team established the Walnuts and Healthy Aging (WAHA) trial which ran from 2012 to 2014 and was designed to examine the impact of bioactive compounds, such as n-3 fatty acids (found in walnuts) on both cognitive function and retinal health. Free-living participants were randomised to receive 30 – 60g/day of walnuts, which were delivered to the intervention group individuals, or to abstain from the nuts for the two years of the trial. One of the secondary outcomes of the original trial was changes in lipoprotein levels. Together with fasting glucose, lipoprotein levels were were measured at baseline at after 2 years. In addition, given that those eating walnuts were consuming more fat and thus likely to experience weight gain, this was also measured and compared with the baseline reading.
There were 636 participants with a mean age of 69 years (67% female) who completed the two-year trial. The mean baseline LDL-C and triglyceride levels were 117 and 105 mg/dL respectively. Among those taking walnuts, mean total cholesterol levels decreased by 4.4%
(-8.5 mg/dL, 95% CI -11.2 to -5.4), LDL-C by 3.6% (-4.3, 95% CI -6.6 to -1.6) and intermediate-density lipoprotein cholesterol by 16.8% (-1.3, 95% CI -1.50 to -1.0). Interestingly, levels of both triglycerides and high-density lipoprotein levels were unchanged. Weight changes in the walnut group were negligible at 0.06kg (95% CI -0.32 to 0.44). Furthermore, LDL-C reductions were higher for men than women (7.9% vs 2.6%, men vs women). In addition, there were also reductions in total LDL particles and small LDL particle number by 4.3% and 6.1% respectively.
The authors suggest that the reduction is LDL-C cholesterol at 4.3 mg/dL was modest and concluded that daily walnut intake may be useful way to improve cardiovascular risk.
Rajaram S et al. Effects of Walnut Consumption for 2 Years on Lipoprotein Subclasses Among Healthy Elders. Findings From the WAHA Randomized Controlled Trial. Circulation 2021.
9th September 2021
It is often said that breakfast (BF) is the most important meal of the day and there are numerous studies indicating the positive health benefits among those who eat BF. For example, some evidence suggests that not eating breakfast is associated with an increased risk of heart disease, a 21% higher risk of developing type 2 diabetes and a greater risk of all-cause mortality. Nevertheless, while these data are relatively consistent, less is known about which BF foods are potentially associated with a lower incidence and risk of cardiovascular events. One dietary component that is present in common BF foods such as oatmeal, fruit and cereals, is fibre. Furthermore, a recent umbrella review of prospective observational studies concluded that higher fibre intake appears to positively impact on not only cardiovascular disease but overall mortality.
These data led a team from the Department of Family Medicine, West Virginia University School of Medicine, West Virginia, US, to confirm the association between BF, dietary fibre and mortality. The team used the National Health and Nutrition Examination Survey (NHANES) dataset and included individuals aged 40 years and over who self-reported on dietary intake between 1999 and 2002. To determine survival information, the team used a 2015 database which provided mortality follow-up details from the NHANES study. Using the NHANES data, the researchers included those who self-reported as BF eaters and based on the foods eaten, categorised dietary fibre intake as high (> 25 g/day) and low (< 25 g/day). Since hypertension, diabetes and cardiovascular disease can negatively impact on mortality, the analysis included these three factors as covariates. The primary outcomes of the study were all-cause and cardiovascular disease (CVD) mortality and the team included a cohort of non-breakfast eaters which served as a control group.
A total of 5761 individuals were identified, 4778 BF eaters with a mean age of 57.5 years (46.6% male) and the remainder, a matched cohort of non-breakfast eaters. The average calorie intake was higher in breakfast eaters compared to non-breakfast eaters (2041.1 vs 1871.1, p = 0.001). Furthermore, dietary fibre intake was also higher among BF eaters (16.9g vs 12.8 g, p < 0.0001). During the follow-up period of approximately 147.6 months, there were 2027 (35.2%) all-cause deaths and 469 (8.1%) CVD deaths. After adjustment for covariates, breakfast eaters had a reduced risk of all-cause mortality (adjusted Hazard ratio, aHR = 0.45, 95% CI 0.32 – 0.63) and CVD mortality (aHR = 0.79). Among BF eaters with a fibre intake > 25g/day, there was a 21% reduction in all-cause mortality (aHR = 0.79, 95% CI 0.66 – 0.96) compared to non-breakfast eaters. While there was a trend towards lower CVD mortality among breakfast eaters with fibre intakes > 25g/day, this was not significant (aHR = 0.82, 95% CI 0.50 – 1.35, p = 0.42). Among non-breakfast eaters, there were no significant associations between fibre intake and either all-cause or CVD mortality.
The authors concluded that the mortality benefit from eating breakfast observed in both their own and earlier studies appears to be linked with higher intake of fibre.
King DE et al. A Relationship Between Mortality and Eating Breakfast and Fiber. J Am Board Fam Med 2021
6th September 2021
Smoking is a risk factor for cardiovascular disease (CVD) and responsible for 1 of every 4 CVD deaths although smoking is a very preventable CVD risk factor. In one observational study of over 8,000 former heavy (i.e., more than 20 cigarettes/day) it was found that within 5 years of cessation, there was a 39% reduced risk of CVD among those who quit, compared to current smokers. Other evidence indicates a potential dose-response relationship between smoking and ischaemic stroke, such that any reduction is beneficial. However, while a meta-analysis has found that reduced use of cigarettes decreases the risk of lung cancer, the impact on CVD was less clear. This led a team from the Department of Family Medicine/Supportive Care Centre, Seoul, Korea, to compare the effect of either smoking cessation or reduction on the risk of cardiovascular disease outcomes. The team used a Korean national health database and collected information of individuals over 40 years of age who had undergone two health examinations in 2009 and again in 2011 to determine any changes in smoking behaviour. A smaller subgroup who had undergone a third examination in 2013 were also included. The team focused on a group of current smokers and excluded those with prior CVD or cancer and used information on smoking status obtained from a biennial national health examination self-administered questionnaire. Individuals were classed as heavy smokers (> 20 cigarettes/day), moderate smokers (10 – 19/day) and light smokers (< 10/day). Compared with the first examination in 2009, participants were then categorised as quitters, reducers I (> 50% reduction), reducers II (20 – 50% reduction), sustainers (reduced by < 20%) and increasers (>20% in smoking). The primary endpoints for the study were newly diagnosed stroke and myocardial infarction (MI) and secondary endpoints included overall mortality, fatal strokes and fatal Mis. Many other health parameters were collected included age, sex, body mass index, duration of smoking, alcohol consumption, levels of exercise, co-morbidities, all of which were adjusted for in the analyses.
A total of 897,975 current smokers with a mean age of 53 years (94.5% male) were followed over 6.2 years. There were a total of 17,748 strokes and 11,271 MI events during the follow-up period. Among smokers, 52.8% were classed as heavy, 37.3% as moderate and the remainder as light during their first examination. Among smoking quitters, there was a significantly reduced risk of stroke (adjusted Hazard ratio, aHR = 0.77, 95% CI 0.74 – 0.81) and MI (aHR = 0.74) compared to sustainers. In addition, smoking cessation was also associated with a significant reduction in all-cause mortality (aHR = 0.92, 95% CI 0.89 – 0.94). However, among reducers I and II, the risk of both stroke and MI were not significantly lower. For example, for reducers I, stroke aHR = 1.02 (95% CI 0.97 – 1.08) and MI aHR = 0.99 (95% CI 0.92 – 1.06).
At the third examination in 2013, quitters who had relapsed to either the level of reducer I, II, sustainer or increaser, had a 42 to 66% increased risk of stroke and a 54 – 69% increased risk of MI compared to quitters, depending where they were in terms of their relapsed level of smoking.
The authors concluded that only smoking cessation and not reduction was associated with a reduced risk of adverse cardiovascular outcomes.
Jeong SM et al. Smoking cessation, but not reduction, reduces cardiovascular disease incidence. Eur Heart J 2021
1st September 2021
According to research presented at the European Stroke Organisation Conference (ESOC), non-traditional risk factors for cardiovascular disease, appear to be increasing more in women than men. Researchers from the University of Zurich, Switzerland, turned to data contained in the Swiss Health Survey. This was established in 1981/82 and designed to provide data from a representative sample on a number of health-related issues such as perceived health status, use of health services and demand for health care. Information is collected every 5 years and since 2010, the data formed part of the Swiss population census.
Using data obtained in 2007, 2012 and 2017 on 22,000 men and women, the researchers identified an increase in the number of women who reported non-traditional risk factors for cardiovascular disease. This change appeared to coincide with an increase in the proportion of women who reported working full-time, which had increased from 38% in 2007 to 44% by 2017. The data showed that the number of individuals reporting stress at work had risen from 59% in 2012 to 66% in 2017. Furthermore, the proportion reporting non-traditional factors such as being tired and fatigued had also increased from 23% to 29%, but had risen to 33% among women compared to 26% in men, with a slightly higher level of severe sleep disorders in women (8%) compared to men (5%).
Fortunately, the study observed that the more traditional cardiovascular disease risk factors had stabilised over the study period, with 27% having hypertension, 18% a raised cholesterol level and 5% diabetes. Nevertheless, while obesity had increased to 11%, the level of smoking had reduced slightly from 10.5 to 9.5 cigarettes per day though both obesity and levels of smoking were higher in men.
According to the study authors, Dr Martin Hänsel and Dr Susanne Wegener, “our study found men were more likely to smoke and be obese than women, but females reported a bigger increase in the non-traditional risk factors for heart attacks and strokes, such as work stress, sleep disorders, and feeling tired and fatigued.”
10-year trends in cardiovascular risk factors in Switzerland: non-traditional risk factors are on the rise in women more than in men. Presented at the European Stroke Organisation Conference, September 2021
23rd July 2021
Elevated levels of low-density lipoprotein cholesterol (LDL-C) leads to the development of atherosclerosis and is a risk factor for cardiovascular disease. Some evidence suggests an association between childhood obesity and the subsequent risk of biochemical abnormalities in adults. Nevertheless, there is a lack of longitudinal data linking the presence of childhood cardiovascular risk factors with adult disease. Furthermore, little is known about the extent to which risk factors such as LDL-C levels vary during childhood and how this might contribute towards atherosclerosis and adverse cardiovascular outcomes in adult life. A better understanding the childhood trajectories of LDL-C cholesterol could lead to improved preventative strategies. In trying to shed more light on this topic, a team from the Division of General Medicine, Columbia University, Irving Medical Centre, New York, turned to data available in the International Childhood Cardiovascular Cohort (i3C) Consortium. While children virtually never experience adverse cardiovascular events, the i3C is the first longitudinal cohort study designed to locate adults with detailed and repeated childhood biological, and physical measurements and includes over 10,000 individuals from several countries. The Irving Medical Centre team used data from i3C individuals who had at least one LDL-C measurement between the ages of 3 and 17 years of age and extracted demographic and body mass index information from these participants. The team considered LDL-C levels greater than 160mg/dl (4.14mmol/l) as consistent with probable familial hypercholesterolaemia (FH) and used the more stringent criteria of an LDL-C of greater than 160mg/dl on at least two occasions and a level of LDL-C of 190mg/dl or greater as a threshold for FH. In order to examine LDL-C trajectories during childhood, the team fitted a linear model of LDL-C against age, adjusting for sex, ethnicity and body mass index.
A total of 15,045 children with a mean age of 9.9 years (48.7% male) were included in the analysis. Overall, 2.8% of children had an LDL-C greater than 160mg/dl and 0.6% had values exceeding 190mg/dL. Using the more stringent criteria, 1% of children had elevated LDL-C levels (> 160mg/dL) on two occasions and 0.3%, levels above 190mg/dl, consistent with FH. Using the linear model it could be seen that mean LDL-C cholesterol levels increased from age 3 to 10 years, decreased from age 10 to 15 but then increased again to reach adult levels. LDL-C levels were consistently and significantly higher in female children and those of Black ethnicity or with a higher body mass index.
In a discussion of their findings, the authors noted how LDL-C levels peaked between ages 9 and 11 and that these levels were comparable to those aged 18 years. This, the authors suggested, highlighted the importance of childhood lipid screening from as early as 9 years of age.
Zhang Y et al. Low-Density Lipoprotein Cholesterol Trajectories and Prevalence of High Low-Density Lipoprotein Cholesterol Consistent with Heterozygous Familial Hypercholesterolemia in US Children. JAMA Pediatr 2021
27th April 2021
In a large, prospective study of nearly half a million individuals, higher intakes of fish intake were associated with a reduced all-cause mortality. One factor associated with biological ageing is the length of telomeres, which are strands of DNA at the ends of chromosomes and there is good evidence that telomere shortening is associated with increased mortality and how among individuals who consume higher amounts of omega-3 fatty acids, there is a reduced risk of telomere shortening. Moreover, increased physiological stress is a risk factor for many physical and mental health diseases and again, there is a suggestion that the pro-inflammatory response to psychological stress is attenuated to some extent by omega-3 fatty acids. Taken together, these results suggest that supplementing with omega-3 fatty acids may positively impact on markers of stress reactivity. This was the hypothesis considered by a team from the Institute for Behaviour Medicine Research, the Ohio State University College of Medicine, Ohio, US who examined a group of individual’s response to a social stress test. The team randomised participants into three groups who received either 2.5g/day, 1.25g/day of omega-3 or placebo for 4 months. At baseline, all participants were required to undergo the stress test which involved delivering a 5-minute speech without the use of aids or notes. Both saliva and blood samples were collected before the stress test and at 0.75, 1.25, 1.75 and 2 hours after and the test repeated at the end of the study. Parameters evaluated included cortisol, telomerase (an enzyme that maintains and restores telomeres) and several pro-inflammatory markers, interleukins 6, 10 and 12 as well as tumour necrosis factor (TNF). Participants were also required to score their anxiety levels before and after the test.
A total of 138 individuals were recruited (63% female) with a mean age of 51.1 years and with 72% of white ethnicity. Among those taking 2.5g/day of omega-3, their salvia cortisol levels were 19% lower throughout the final stress test compared to those given placebo (p = 0.01) although this difference was not significant for the 1.25g/day group. Similarly, the high dose supplement group had a 33% lower interleukin-6 level compared to placebo (p = 0.007). However, there were no differences with the other interleukin levels or of TNF. While telomerase levels remained unchanged in both supplement groups, levels dropped between 45 and 120 minutes after the stress test by 24%.
The authors commented on how 2.5g/day of omega-3 fatty acid supplementation blocked the stress-related decline in telomerase level as well as reducing levels of both cortisol and the pro-inflammatory interleukin-6 in a dose dependent manner. They suggested that omega-3 supplements had a unique stress-buffering effect on biomarkers of cellular ageing, concluding that while their data were preliminary, if replicated, it could limit the impact of repeated stress.
Madison AA et al. Omega-3 supplementation and stress reactivity of cellular ageing biomarkers: an ancillary sub-study of a randomised, controlled trial in midlife adults. Mol Psychiatry 2021.