Trends in Glucagon-Like Peptide-1 Receptor Agonist Social Media Posts Using Artificial Intelligence.

Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have surged in popularity in recent years, with discussions about their on-label and off-label use spilling into the public forum. No study has analyzed online discussions about GLP-1RAs. Objectives: The purpose of this study was to analyze perceptions of GLP-1RAs on social media. Methods: We analyzed GLP-1RA-related posts on Reddit between May 28, 2013, and June 1, 2023. All posts were identified that included generic or brand names of GLP-1RAs. Post volume on Reddit was compared to search interest on Google over time. An artificial intelligence (AI) pipeline consisting of a semi-supervised natural language processing model (Bidirectional Encoder Representations from Transformers [BERT]), a dimensionality reduction technique, and a clustering algorithm was used to cluster posts into related topics. Discussion sentiment was classified using a pretrained BERT model and assessed qualitatively. Results: 14,390 GLP-1RA-related Reddit posts by 8,412 authors were identified. Ninety-four percent of posts were created after 2021, consistent with search interest trend on Google. We used the AI model to categorize posts into 30 topics which were hierarchically grouped by the model based on shared content. Posts were identified among communities for individuals with diabetes and obesity, as well as for diseases without a Food and Drug Administration-approved indication. Most posts had a negative sentiment using the pretrained model, acknowledging the pretrained model is at risk for misclassifying posts. Conclusions: AI can generate insights on perceptions of GLP-1RAs on social media. Common themes included success stories of improving diabetes and obesity management, struggles with insurance coverage, and questions regarding diet, side effects, and medication administration.

A Case-Based Approach to the Management of Patients with Chronic Coronary Disease: Updates from the 2023 AHA/ACC Guidelines.

The 2023 American Heart Association (AHA)/American College of Cardiology (ACC) Multisociety Guideline for the Management of Patients with Chronic Coronary Disease presents important updates to the care of patients with chronic coronary disease (1). The recommendations of these guidelines inform the care for patients with (1) asymptomatic coronary artery disease, (2) stable angina or equivalent symptoms (e.g., dyspnea upon exertion), (3) symptomatic nonobstructive coronary disease including coronary microvascular dysfunction and vasospasm, and (4) left ventricular (LV) systolic dysfunction with known coronary artery disease. In this review, we aim to demonstrate key recommendations in the 2023 guideline using the following four hypothetical cases.

Predictors of incident stroke among individuals without coronary artery calcification: A pooled cohort analysis from the Multi-Ethnic Study of Atherosclerosis, Jackson Heart Study, and Framingham Heart Study.

INTRODUCTION: The absence of coronary artery calcium (CAC = 0) is associated with low risk of stroke events; however, predictors of incident stroke among those with CAC = 0 are not known. METHODS: Individual participant-level data were pooled from three prospective cohorts (Multi-Ethnic Study of Atherosclerosis, Jackson Heart Study, and Framingham Heart Study). Multivariable-adjusted Cox proportional hazards models were used to study the association between cardiovascular risk factors and incident adjudicated stroke among individuals with CAC = 0 who were free of clinical atherosclerotic cardiovascular disease at baseline. RESULTS: Among 6180 participants (mean age 53 [SD 11] years, 62% women, and 44% White, 36% Black, and 20% other individuals), over a median (IQR) follow up of 15 (12-16) years, there were 122 strokes (95 ischemic, 27 hemorrhagic) with an overall unadjusted event rate of 2.0 per 1000 person-years. After multivariable adjustment, risk factors associated with overall stroke included (hazard ratio [95% CI]) systolic blood pressure (SBP): 1.19 (1.05-1.36) per 10-mmHg increase and carotid intima-media thickness (CIMT): 1.21 (1.04-1.42) per 0.1-mm increment. Current cigarette smoking: 2.68 (1.11-6.50), SBP: 1.23 (1.06-1.42) per 10-mmHg increase, and CIMT: 1.25 (1.04-1.49) per 0.1-mm increment were associated with ischemic stroke, whereas C-reactive protein was associated with hemorrhagic stroke risk (0.49, 0.25-0.93). CONCLUSION: In a large cohort of individuals with CAC = 0, the rate for incident stroke was low (2.0 per 1000-person years) and was associated with modifiable risk factors.

Climate change and cardiovascular health: Recent updates and actions for healthcare.

Climate change is a public health crisis predominantly due to fossil fuel combustion, that challenges planetary and human health. Considerable evidence exists to demonstrate the impact climate change has on cardiovascular disease primarily through air pollution, and non-optimal temperature. Conversely, healthcare systems themselves contribute substantially to climate change. Many clinicians personally report a sense of responsibility to reduce the detrimental impact of parts of our healthcare system on the environment. Roadmaps exist to guide decarbonization and reduce pollution in the healthcare sector. The first step in minimizing the climate impact of the provision of cardiovascular care is to determine the carbon footprint of highly resource dependent sectors such as critical care cardiology as well as the cardiac catheterization and electrophysiology laboratories. This should be followed by sustainable changes to address healthcare waste and energy use. Engagement from healthcare leadership, governmental organizations and major cardiac societies will be necessary to impact meaningful change.

Neurocardiac Axis Physiology and Clinical Applications.

The neurocardiac axis constitutes the neuronal circuits between the arteries, heart, brain, and immune organs (including thymus, spleen, lymph nodes, and mucosal associated lymphoid tissue) that together form the cardiovascular brain circuit. This network allows the individual to maintain homeostasis in a variety of environmental situations. However, in dysfunctional states, such as exposure to environments with chronic stressors and sympathetic activation, this axis can also contribute to the development of atherosclerotic vascular disease as well as other cardiovascular pathologies and it is increasingly being recognized as an integral part of the pathogenesis of cardiovascular disease. This review article focuses on 1) the normal functioning of the neurocardiac axis; 2) pathophysiology of the neurocardiac axis; 3) clinical implications of this axis in hypertension, atherosclerotic disease, and heart failure with an update on treatments under investigation; and 4) quantification methods in research and clinical practice to measure components of the axis and future research areas.

Should We Use Aspirin or P2Y12 Inhibitor Monotherapy in Stable Ischemic Heart Disease?

PURPOSE OF REVIEW: To summarize the recent evidence and guideline recommendations on aspirin or P2Y12 inhibitor monotherapy in patients with stable ischemic heart disease and provide insights into future directions on this topic, which involves transition to a personalized assessment of bleeding and thrombotic risks. RECENT FINDINGS: It has been questioned whether the evidence for aspirin as the foundational component of secondary prevention in patients with coronary artery disease aligns with contemporary pharmaco-invasive strategies. The recent HOST-EXAM study randomized patients who had received dual antiplatelet therapy for 6 to 18 months without ischemic or major bleeding events to either clopidogrel or aspirin for a further 24 months, and demonstrated that the patients in the clopidogrel arm had significantly lower rates of both thrombotic and bleeding complications compared to those in the aspirin arm. The patient-level PANTHER meta-analysis showed that in patients with established coronary artery disease, P2Y12 inhibitor monotherapy was associated with lower rates of myocardial infarction, stent thrombosis as well as gastrointestinal bleeding and hemorrhagic stroke compared to aspirin monotherapy, albeit with similar rates of all-cause mortality, cardiovascular mortality and major bleeding. Long-term low-dose aspirin is recommended for secondary prevention in patients with stable ischemic heart disease, with clopidogrel monotherapy being acknowledged as a feasible alternative. Dual antiplatelet therapy for six months after percutaneous coronary intervention remains the standard recommendation for patients with stable ischemic heart disease. However, the duration of dual antiplatelet therapy may be shortened and followed by P2Y12 inhibitor monotherapy or prolonged based on individualized evaluation of the patient's risk profile.

Intra-individual variability in lipoprotein(a): the value of a repeat measure for reclassifying individuals at intermediate risk.

Aims: Lipoprotein(a) [Lp(a)] levels are predominantly genetically determined and repeat measurements are generally considered unlikely to be clinically useful. However, the temporal variation of Lp(a) is not well characterized. Our aim was to determine the intra-individual variability of Lp(a) and whether a repeated measure reclassified Lp(a)-specific cardiovascular risk using the European Atherosclerosis Society (EAS) consensus statement risk categories. Methods and results: This retrospective cohort study analysed initial and repeated serum Lp(a) levels measured using the same methodology from 609 individuals in the Nashville Biosciences database, a de-identified electronic medical records database. Baseline and follow-up paired values were significantly different (P < 0.05), with an absolute change of ≥10 mg/dL in 38.1% [95% CI 34.2-42%] and a >25% change in 40.5% [95% CI 36.6-44.3%] of individuals. Although the categories of those whose values were in the EAS low-risk and high-risk categories did not change, 53% of those in the intermediate 'grey-zone' category transitioned to either the low-risk (20%) or high-risk (33%) category. Black individuals exhibited greater variability than White individuals and women exhibited greater variability than men. There was a positive correlation between the baseline Lp(a) levels and the absolute changes in Lp(a), (r = 0.59, P < 0.01). Conclusion: Temporal-related changes in Lp(a) variability were present in many individuals. A repeat Lp(a) measure may allow more precise Lp(a)-specific cardiovascular risk prediction for individuals whose initial value is in the EAS-defined intermediate 'grey-zone' category. Lp(a) variability should be included in calculating the expected effect sizes in future clinical research studies targeting Lp(a).

Public Health Messaging to Older Adults About Hypertension.

Hypertension is a major risk factor for cardiovascular disease, cognitive decline, and frailty. Given the increasing burden of hypertension in the aging population, it is imperative to improve hypertension management in that population. Apart from variations in treatment goals, challenges such as polypharmacy, medication side effects, and therapeutic inertia hinder adherence to guideline-directed medical therapies among older people. Effective public health messaging is essential for spreading evidence-based guidelines, raising awareness among clinicians, enhancing patient education and health literacy, and implementing community-based strategies to tackle hypertension. This review examines the current state of public messaging on hypertension in older adults.

Coronary Artery Calcium for Risk Stratification Among Persons With Very High HDL Cholesterol.

Background: Compared to normal high-density lipoprotein (HDL) cholesterol values, very high HDL cholesterol is associated with a higher incidence of mortality and atherosclerotic cardiovascular disease (ASCVD). As such, clinical risk stratification among persons with very high HDL cholesterol is challenging. Objectives: Among persons with very high HDL cholesterol, the purpose was to determine the prevalence of coronary artery calcium (CAC) and compare the association between traditional risk factors vs CAC for all-cause mortality and ASCVD. Methods: The primary analysis was completed among 446 participants from the Cedars-Sinai Medical Center of the CAC Consortium with very high HDL cholesterol (≥77 mg/dL in men, ≥97 mg/dL in women). Cox proportional hazards regression assessed the association of CAC and traditional risk factors with all-cause mortality during a median follow-up of 10.7 years. Replication and validation analyses were performed for all-cause mortality among 119 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) with very high HDL cholesterol, who also had information on incident ASCVD. Results: The mean age was 57.9 years old, 49% were women, and the median HDL cholesterol was 98 mg/dL. One-half of participants (50%) had prevalent CAC, in whom the median CAC score was 118. Prevalent CAC conferred a 3.6-fold higher risk of all-cause mortality (HR: 3.64; 95% CI: 1.21-11.01), which appeared to be a more robust predictor than individual traditional risk factors beyond age. In the validation sample, prevalent CAC but not individual traditional risk factors were associated with all-cause mortality (HR: 2.39; 95% CI: 1.07-5.34) and a 4.0-fold higher risk of ASCVD (HR: 4.06; 95% CI: 1.11-14.84). Conclusions: Measurement of CAC may facilitate clinical risk assessment among individuals with very high HDL cholesterol.

COVID-19 in the Initiation and Progression of Atherosclerosis: Pathophysiology During and Beyond the Acute Phase.

The incidence of atherosclerotic cardiovascular disease is increasing globally, especially in low- and middle-income countries, despite significant efforts to reduce traditional risk factors. Premature subclinical atherosclerosis has been documented in association with several viral infections. The magnitude of the recent COVID-19 pandemic has highlighted the need to understand the association between SARS-CoV-2 and atherosclerosis. This review examines various pathophysiological mechanisms, including endothelial dysfunction, platelet activation, and inflammatory and immune hyperactivation triggered by SARS-CoV-2 infection, with specific attention on their roles in initiating and promoting the progression of atherosclerotic lesions. Additionally, it addresses the various pathogenic mechanisms by which COVID-19 in the post-acute phase may contribute to the development of vascular disease. Understanding the overlap of these syndromes may enable novel therapeutic strategies. We further explore the need for guidelines for closer follow-up for the often-overlooked evidence of atherosclerotic cardiovascular disease among patients with recent COVID-19, particularly those with cardiometabolic risk factors.

Advancements in Incident Heart Failure Risk Prediction and Screening Tools.

Heart failure (HF) is a major cause of mortality and morbidity in the United States that carries substantial healthcare costs. Multiple risk prediction models and strategies have been developed over the past 30 years with the aim of identifying those at high risk of developing HF and of implementing preventive therapies effectively. This review highlights recent developments in HF risk prediction tools including emerging risk factors, innovative risk prediction models, and novel screening strategies from artificial intelligence to biomarkers. These developments allow more accurate prediction, but their impact on clinical outcomes remains to be investigated. Implementation of these risk models in clinical practice is a considerable challenge, but HF risk prediction tools offer a promising opportunity to improve outcomes while maintaining value.

Testing practices and clinical management of lipoprotein(a) levels: A 5-year retrospective analysis from the Johns Hopkins Hospital.

Objective: Elevated lipoprotein(a) [Lp(a)] is an independent, genetically determined risk factor for atherosclerotic cardiovascular disease (ASCVD). We evaluated the frequency of testing for elevated Lp(a) and subsequent management at the Johns Hopkins Hospital, a large academic medical center, over a 5-year period. Methods: The Johns Hopkins Hospital (JHH) electronic medical record was queried to identify patients with an encounter between 2017 and 2021, either with established ASCVD or at increased risk, defined as being on any lipid lowering medication or having LDL-C ≥ 190 mg/dL. The frequency of Lp(a) testing and of elevated levels were identified for each year. Results: Among 111,350 unique adult patients, 2,785 (2.5 %) had at least one Lp(a) test. Patients with Lp(a) testing, compared to those without testing, were younger (mean age 56 years vs. 66 years), more often female (49 % vs. 44 %), Black (24.7 % vs. 24.6 %) or "other" race/ethnicity (12 % vs 10 %), and had higher LDL-C levels (median 118 vs. 91 mg/dL; p < 0.001). The number and frequency of Lp(a) testing increased from 167 (0.57 %) in 2017 to 1155 (5.67 %) in 2021. Lp(a) levels were abnormal in 43.4 % of patients (moderate [75-125 nmol/L]: 10.3 %, high [126-600 nmol/L]: 32.2 %, severe [>600 nmol/L]: 0.9 %). Among 920 patients with high or severe Lp(a) levels, 200 (22 %) had a subsequent referral to cardiology or lipid specialist, and 180 (20 %) had a new lipid-lowering medication prescribed in the subsequent 18 months. Conclusion: Based on a single-center experience, the frequency of incident Lp(a) testing among increased-risk patients was low but increased significantly over 5-years, likely due to Lipid Clinic referrals with reflex Lp(a) testing and greater awareness about this risk factor. Future work should target appropriate population based Lp(a) testing strategies and clinical decision-making regarding risk management once Lp(a) elevation is diagnosed.

Assessing athletes beyond routine screening: Incorporating essential factors to optimize cardiovascular health and performance.

The American Heart Association (AHA) has devised Life's Essential 8, a set of eight evidence-based health behaviors that play a crucial role in optimizing cardiovascular health and overall well-being. In addition to Life's Essential 8, enhanced screening for Cardiovascular-Kidney-Metabolic (CKM) Syndrome risk factors into routine athlete screening also provides a more comprehensive approach for ensuring athlete safety and long-term health. Incorporating Life's Essential 8 and CKM Syndrome metrics into athlete health evaluations will improve the sports performance of athletes and help optimize their long-term health.

Association of aortic valve calcium with dementia and stroke: The Multi-Ethnic Study of Atherosclerosis.

BACKGROUND AND AIMS: Calcific aortic valve disease is associated with increased thrombin formation, platelet activation, decreased fibrinolysis, and subclinical brain infarcts. We examined the long-term association of aortic valve calcification (AVC) with newly diagnosed dementia and incident stroke in the Multi-Ethnic Study of Atherosclerosis (MESA). METHODS: AVC was measured using non-contrast cardiac CT at Visit 1. We examined AVC as a continuous (log-transformed) and categorical variable (0, 1-99, 100-299, ≥300). Newly diagnosed dementia was adjudicated using International Classification of Disease codes. Stroke was adjudicated from medical records. We calculated absolute event rates (per 1000 person-years) and multivariable adjusted Cox proportional hazards ratios (HR). RESULTS: Overall, 6812 participants had AVC quantified with a mean age of 62.1 years old, 52.9 % were women, and the median 10-year estimated atherosclerotic cardiovascular disease (ASCVD) risk was 13.5 %. Participants with AVC >0 were older and less likely to be women compared to those with AVC=0. Over a median 16-year follow-up, there were 535 cases of dementia and 376 cases of stroke. The absolute risk of newly diagnosed dementia increased in a stepwise pattern with higher AVC scores, and stroke increased in a logarithmic pattern. In multivariable analyses, AVC was significantly associated with newly diagnosed dementia as a log-transformed continuous variable (HR 1.09; 95 % CI 1.04-1.14) and persons with AVC ≥300 had nearly a two-fold higher risk (HR 1.77; 95 % CI 1.14-2.76) compared to those with AVC=0. AVC was associated with an increased risk of stroke after adjustment for age, sex, and race/ethnicity, but not after adjustment for ASCVD risk factors. CONCLUSIONS: After multivariable adjustment, AVC >0 was significantly associated with an increased risk of newly diagnosed dementia, but not incident stroke. This suggests that AVC may be an important risk factor for the long-term risk of dementia beyond traditional ASCVD risk factors.