A new study published in PLOS One found that COVID infection is associated with a nearly six-fold increase in cardiovascular disease (CVD) diagnoses over 12 months after the infection.
The study analysed of UK electronic health records, comparing the risks of new diabetes mellitus (DM) and CVD diagnoses in the 12 months after infection. Researchers matched a cohort of 428 650 COVID patients matched to controls.
There was an 80% increased risk of DM diagnosis in the first month after COVID infection, a trend that has been echoed in previous studies, although those studies’ results seem to indicate a temporary form of the disease resulting from the acute stress of viral infection.
The findings showed that the largest increases were in pulmonary embolism (Relative Risk [RR] 11.51) and in atrial arrhythmias (RR 6.44). New CVD diagnoses rose five weeks after infection and incidence declined within 12 weeks to a year and returned to baseline or showed a net decrease. Increased risk for new DM diagnoses remained elevated by 27% for up to 12 weeks.
“It’s definitely reassuring that over the longer timeframe, cardiovascular disease and diabetes risk does seem to return to baseline levels,” study author Emma Rezel-Potts, PhD, told The Guardian. “But we do have to be cautious in the acute period with cardiovascular disease and take note that the risk of diabetes seems to be elevated for several months, so that could be a good opportunity for risk prevention.”
She also stressed that the findings could be explained by many factors. For example, the COVID patients in the study were more likely to be overweight and had more underlying health problems compared to uninfected controls, predisposing them to DM and CVD. Additionally, some may have had underlying conditions which were discovered when they were treated for COVID.
Salt restriction has long been held to be a key component of heart failure treatment, but cutting back too much may actually worsen the outcomes for people with preserved ejection fraction, suggests research published in Heart.
The findings indicate that younger people and those of black and other ethnicities seem to be most at risk.
Salt restriction is frequently recommended in heart failure guidelines, but the optimal restriction range (from less than 1.5g to less than 3g daily) and its effect on patients with heart failure with preserved ejection fraction (HFpEF) is less clear as they have often been excluded from relevant studies.
HFpEF, which accounts for half of all heart failure cases, occurs when the lower left chamber of the heart (left ventricle) isn’t able to fill properly with blood (diastolic phase), so reducing the amount of blood pumped out into the body.
In a bid to explore the association with salt intake further, the researchers drew on secondary analysis of data from 1713 people aged 50 and above with heart failure with preserved ejection fraction who were part of the TOPCAT trial.
A phase III, randomised, double-blind, placebo-controlled study, this trial was designed to find out if the drug spironolactone could effectively treat symptomatic heart failure with preserved ejection fraction.
Participants were asked how much salt they routinely added to the cooking of staples, such as rice, pasta, and potatoes; soup; meat; and vegetables, and this was scored as: 0 points (none); 1 (⅛tsp); 2 (¼tsp); and 3 (½+tsp).
They were followed up for an average of three years for the primary endpoint, a composite of death from cardiovascular disease or admission to hospital for heart failure plus aborted cardiac arrest. Secondary outcomes were all cause mortality and cardiovascular disease mortality plus hospitalisation for heart failure.
Around half the participants (816) had a cooking salt score of zero: more than half of them were men (56%) and most were of white ethnicity (81%). They weighed significantly more and had a lower diastolic blood pressure (70 mm Hg) than those with a cooking salt score above zero (897).
They had also been admitted to hospital more often for heart failure, were more likely to have type 2 diabetes, poorer kidney function, to be taking meds to control their heart failure, and to have a reduced left ventricular ejection fraction (lower cardiac output).
Participants with a cooking salt score above zero were at significantly lower risk of the primary endpoint than those whose score was zero, mainly driven by the fact that they were less likely to be hospitalised for heart failure. But all-cause mortality or CVD mortality was no higher than those whose cooking salt score was zero.
Those aged 70 or younger were significantly more likely to benefit from adding salt to their cooking than were those older than 70 in terms of the primary endpoint and admission to hospital for heart failure.
Similarly, those of black and other ethnicities seemed to benefit more from adding salt compared with white participants, although the numbers were small.
Gender, previous hospitalisation for heart failure, and the use of heart failure meds weren’t associated with heightened risks of the measured outcomes and cooking salt score.
This is an observational study, and as such, can’t establish cause. Not all relevant data from the TOPCAT trial were available, while the cooking salt score was self-reported, acknowledge the researchers. And reverse causation, whereby people with poorer health might have been advised to further restrict their salt intake, can’t be ruled out.
Lower sodium intake is usually associated with lower blood pressure and a reduced risk of cardiovascular disease in the general public and in those with high blood pressure. It is thought that it reduces fluid retention and the triggering of the hormones involved in blood pressure regulation.
But restricting salt intake to control heart failure is less straightforward, say the researchers. It may prompt intravascular volume contraction, which could, in turn, reduce congestion and the requirement for water tablets to ease fluid retention.
But the researchers pointed out that the that the volume of plasma in the blood, an indicator of congestion, wasn’t significantly associated with cooking salt score – suggesting that low sodium intake didn’t ease fluid retention in people with heart failure with preserved ejection fraction.
“Overstrict dietary salt intake restriction could harm patients with [heart failure with preserved ejection fraction] and is associated with worse prognosis. Physicians should reconsider giving this advice to patients,” they conclude.
Patients with a certain subtype of age-related macular degeneration (AMD) are at significant risk for cardiovascular disease and stroke, according to new research published in Retina.
“For the last three decades researchers have suggested an association between AMD and cardiovascular disease, but there has been no conclusive data on this until now. Our retinal team answered this important question by focusing on two different varieties of AMD that can be seen with advanced retinal imaging. We discovered that only one form of AMD, that with subretinal drusenoid deposits, is tightly connected to high-risk vascular diseases, and the other form, known as drusen, is not,” explained lead author R. Theodore Smith, MD, PhD, Professor at Mount Sinai. “If ophthalmologists diagnose or treat someone with the specific subretinal drusenoid deposits form of AMD, but who otherwise seems well, that patient may have significant undetected heart disease, or possibly carotid artery stenosis that could result in a stroke. We foresee that in the future, as an improved standard of care, such patients will be considered for early referral to a cardiologist for evaluation and possibly treatment.”
AMD is the leading cause of visual impairment and blindness over the age of 65. Drusen is one major form of early AMD: small yellow cholesterol deposits form in a layer under the retina, depriving it of blood and oxygen, leading to vision loss. Drusen formation can be slowed by appropriate vitamin supplementation.
The other major form of early AMD is the presence of subretinal drusenoid deposits (SDD), which is lesser known, which needs advanced retinal imaging to detect. These deposits are also made of fatty lipids and other materials, but form in a different layer beneath the light sensitive retina cells, where they are also associated with vision loss. There is no known treatment for SDD at present.
Mount Sinai researchers analysed 126 patients with AMD, using optical coherence tomography (OCT) which captures high-resolution cross-sectional scans of the retina. Patients also answered health history questionnaires. Of the patients on the study, 62 had SDD and 64 had drusen; 51 of the 126 total patients (40%) reported having cardiovascular disease or a past stroke, and most (66%) of those patients had SDD. By contrast, of the 75 patients who did not have known heart disease or stroke, relatively few (19%) had SDD. The odds of patients with cardiovascular disease or stroke having SDD was three times than in patients without.
The researchers suggested that the underlying cardiovascular disease likely compromises blood circulation in the eye, leading to the SDDs beneath the retina.
“We believe poor ocular circulation that causes SDDs is a manifestation of underlying vascular disease. This has important public health implications and can facilitate population screening and disease detection with major impact,” explained author Jagat Narula, MD, PhD, Associate Dean of Global Affairs and Professor of Medicine (Cardiology), and Radiology, at the Icahn School of Medicine at Mount Sinai. “Seen in an eye clinic, such patients should be prompted to see a cardiologist. On the other hand, if clinically substantiated in prospective studies, SDDs could emerge as a risk marker for underlying vascular disease in asymptomatic patients in primary care or a cardiology clinic. The temporal relationship between SDDs and macrovascular disease will also need to be established in prospective studies which are currently in progress.”
Analysis of patient blood samples revealed genetic risk factors may also play a role in SDD cases in addition to vascular causes. Specifically, they found that the ARMS2 gene acted independently of vascular disease to cause SDD in some patients.
“This study further demonstrates that AMD is not a single condition or an isolated disease, but is often a signal of systemic malfunction which could benefit from targeted medical evaluation in addition to localised eye care,” noted Richard B. Rosen, MD, Chief of the Retina Service for the Mount Sinai Health System. “It helps bring us one step closer to unraveling the mystery of this horrible condition which robs so many patients of the pleasure of good vision during their later years. “
Sleep duration is now considered an essential component for ideal heart and brain health. Life’s Essential 8™ cardiovascular health score replaces Life’s Simple 7™, according to a new American Heart Association advisory published in Circulation.
Other updates to the measures of optimal cardiovascular health, now for anyone ages 2 and older, include a new guide to assess diet; accounting for exposure to second-hand smoke and vaping; using non-HDL cholesterol instead of total cholesterol to measure blood lipids; and expanding the blood sugar measure to include haemoglobin A1c to assess Type 2 diabetes risk.
“The new metric of sleep duration reflects the latest research findings: sleep impacts overall health, and people who have healthier sleep patterns manage health factors such as weight, blood pressure or risk for Type 2 diabetes more effectively,” said American Heart Association President Professor Donald M. Lloyd-Jones, MD, who led the advisory writing group. “In addition, advances in ways to measure sleep, such as with wearable devices, now offer people the ability to reliably and routinely monitor their sleep habits at home.”
The Association first defined the seven metrics for cardiovascular health in 2010 to identify the specific health behaviours and health factors that drive optimal heart and brain health.
After 12 years and more than 2400 scientific papers on the topic, new discoveries in heart and brain health and in the ways to measure cardiovascular health provided an opportunity to revisit each health component in more detail. Four of the original metrics have been redefined for consistency with newer clinical guidelines or compatibility with new measurement tools. Also, the scoring system can now be applied to anyone ages 2 and older.
The Life’s Essential 8™ components of optimal cardiovascular health are divided into two major areas: health behaviours (diet, physical activity, nicotine exposure and sleep) and health factors (BMI, cholesterol levels, blood sugar and blood pressure). “The idea of optimal cardiovascular health is important because it gives people positive goals to work toward at any stage of life,” said Lloyd-Jones.
“Life’s Simple 7™ has served as a proven, powerful tool for understanding how to achieve healthy aging and ways to improve cardiovascular health while decreasing the risks of developing heart disease and stroke, as well as cancer, dementia and many other chronic diseases,” he said. “Given the evolving research, it was important to address some limitations to the original metrics, particularly in ways they’ve been applied to people from diverse racial and ethnic populations.”
Prof Lloyd-Jones explained that some of the previous metrics, such as diet, were not as sensitive to differences among people, or as responsive to changes over time within a single individual. “We felt it was the right time to conduct a comprehensive review of the latest research to refine the existing metrics and consider any new metrics that add value to assessing cardiovascular health for all people.”
Life’s Essential 8™ includes:
Diet (updated): A new guide to assess diet quality for adults and children at the individual level (for individual health care and dietary counselling) and at the population level (for research and public health purposes).
Physical activity (no changes): The optimal level is 150 minutes of moderate physical activity or more per week or 75 minutes per week of vigorous-intensity physical activity for adults; 420 minutes or more per week for children ages 6 and older; and age-specific modifications for younger children.
Nicotine exposure (updated): Use of inhaled nicotine-delivery systems, which includes e-cigarettes or vaping devices, is added since the previous metric only monitored traditional, combustible cigarettes. This reflects use by adults and youth and their implications on long-term health. Life’s Essential 8™ also includes second-hand smoke exposure for children and adults.
Sleep duration (new): Sleep duration is associated with cardiovascular health. Measured by average hours of sleep per night, the ideal level is 7-9 hours daily for adults. Ideal daily sleep ranges for children are 10-16 hours per 24 hours for ages 5 and younger; 9-12 hours for ages 6-12 years; and 8-10 hours for ages 13-18 years.
Body mass index (no changes): The writing group acknowledges that body mass index (BMI) is an imperfect metric, yet it is easily calculated and widely available; therefore, BMI continues as a reasonable gauge to assess weight categories that may lead to health problems. BMI of 18.5–24.9 is associated with the highest levels of cardiovascular health. The writing group notes that BMI ranges and the subsequent health risks associated with them may differ among people from diverse racial or ethnic backgrounds or ancestry. This aligns with the World Health Organization’s recommendations to adjust BMI ranges for people of Asian or Pacific Islander ancestry because recent evidence indicates their risk of conditions such as CVD or Type 2 diabetes is higher at a lower BMI.
Blood lipids (updated): The metric for blood lipids (cholesterol and triglycerides) is updated to use non-HDL cholesterol as the preferred number to monitor, rather than total cholesterol. Other forms of cholesterol, when high, are linked to CVD risk. This shift is made because non-HDL cholesterol can be measured without fasting beforehand (thereby increasing its availability at any time of day and implementation at more appointments) and reliably calculated among all people.
Blood glucose (updated): This metric is expanded to include the option of haemoglobin A1c readings or blood glucose levels for people with or without Type 1 or Type 2 diabetes or prediabetes. Haemoglobin A1c can better reflect long-term glycaemic control.
Blood pressure (no changes): Blood pressure criteria remain unchanged from the Association’s 2017 guidelines that established levels less than 120/80 mm Hg as optimal, and hypertension defined as 130-139 mm Hg systolic pressure (the top number in a reading) or 80-89 mm Hg diastolic pressure (bottom number).
Each component of Life’s Essential 8™, which is assessed by the My Life Check tool, has an updated scoring system ranging from 0 to 100 points. The overall cardiovascular health score from 0 to 100 points is the average of the scores for each of the 8 health measures. Overall scores below 50 indicate “poor” cardiovascular health, and 50-79 is considered “moderate” cardiovascular health. Scores of 80 and above indicate “high” cardiovascular health. The advisory recommends measuring cholesterol, blood sugar, blood pressure, height and weight at least every five years for the most complete and accurate Life’s Essential 8™ score.
The writing group also reviewed data about the impacts of stress, mental health and social determinants of health, such as access to health care, income or education level, and structural racism, which are critical to understanding the foundations of health, particularly among people from diverse racial and ethnic populations.
“We considered social determinants of health carefully in our update and determined more research is needed on these components to establish their measurement and inclusion in the future,” said Lloyd-Jones. “Nonetheless, social and structural determinants, as well as psychological health and well-being, are critical, foundational factors in an individual’s or a community’s opportunity to preserve and improve cardiovascular health. We must consider and address all of these issues for people to have the opportunity for a full, healthy life as measured by Life’s Essential 8™.”
Around one in 500 men could be carrying an extra sex chromosome (X or Y), putting them at increased risk of diseases such as type 2 diabetes, atherosclerosis and thrombosis, according to a study published in Genetics in Medicine.
Researchers from the universities of Cambridge and Exeter analysed genetic data on 200 000 men aged 40 to 70 from UK Biobank. They found 356 men who carried either an extra X chromosome or an extra Y chromosome.
Some men have an extra X or Y chromosome – XXY or XYY, which is usually not obvious without a genetic test. Men with extra X chromosomes, a condition known as Klinefelter syndrome, are sometimes identified during investigations of delayed puberty and infertility; however, most are unaware that they have this condition. Men with an extra Y chromosome tend to be taller as boys and adults, but otherwise they have no distinctive physical features.
In today’s study, the researchers identified 213 men with an extra X chromosome and 143 men with an extra Y chromosome. As the participants in UK Biobank tend to be ‘healthier’ than the general population, this suggests that around one in 500 men may carry an extra X or Y chromosome.
Only a small minority of these men had a diagnosis of sex chromosome abnormality on their medical records or by self-report: fewer than one in four (23%) men with XXY and only one of the 143 XYY men (0.7%) had a known diagnosis.
By linking genetic data to routine health records, the team found that men with XXY have much higher chances of reproductive problems, including a three-fold higher risk of delayed puberty and a four-fold higher risk of being childless. These men also had significantly lower blood concentrations of testosterone. Men with XYY appeared to have a normal reproductive function.
Men with either XXY or XYY had higher risks of several other health conditions: a three-fold higher risk of developing type 2 diabetes, six-fold risk of venous thrombosis, three-fold risk of pulmonary embolism, and four-fold risk of chronic obstructive pulmonary disease (COPD).
It is unclear why an extra chromosome should increase the risk, said the researchers, or why the risks were so similar regardless of which sex chromosome was duplicated.
Yajie Zhao, a PhD student at the Medical Research Council (MRC) Epidemiology Unit at the University of Cambridge, the study’s first author, said: “Even though a significant number of men carry an extra sex chromosome, very few of them are likely to be aware of this. This extra chromosome means that they have substantially higher risks of a number of common metabolic, vascular, and respiratory diseases — diseases that may be preventable.”
Professor Ken Ong, also from the MRC Epidemiology Unit at Cambridge and joint senior author, added: “Genetic testing can detect chromosomal abnormalities fairly easily, so it might be helpful if XXY and XYY were more widely tested for in men who present to their doctor with a relevant health concern.
“We’d need more research to assess whether there is additional value in wider screening for unusual chromosomes in the general population, but this could potentially lead to early interventions to help them avoid the related diseases.”
Professor Anna Murray, at the University of Exeter, said: “Our study is important because it starts from the genetics and tells us about the potential health impacts of having an extra sex chromosome in an older population, without being biased by only testing men with certain features as has often been done in the past.”
Previous studies have found that around one in 1,000 females have an additional X chromosome, which can result in delayed language development and accelerated growth until puberty, as well as lower IQ levels compared to their peers.
Research published in eLife has shown how moderate egg consumption can increase the amount of heart-healthy metabolites in the blood. The findings suggest that eating up to one egg per day may help lower the risk of developing cardiovascular disease.
A rich source of dietary cholesterol, eggs also contain a variety of essential nutrients. Eggs have long had a bad rap when it comes to cardiovascular health, with conflicting evidence as to whether egg consumption is beneficial or harmful to heart health. A large study in China showed that those who ate one egg a day had a lower cardiovascular disease risk than those who ate eggs occasionally. To explore this, researchers carried out a population-based study exploring how egg consumption affects markers of cardiovascular health in the blood.
“Few studies have looked at the role that plasma cholesterol metabolism plays in the association between egg consumption and the risk of cardiovascular diseases, so we wanted to help address this gap,” explained first author Lang Pan, MSc at the Department of Epidemiology and Biostatistics, Peking University, Beijing, China.
Pan and the team selected 4778 participants from the China Kadoorie Biobank, 3401 of whom had a cardiovascular disease and 1377 did not. Measuring 225 metabolites in plasma samples taken from the participants’ blood, they identified 24 that were associated with self-reported levels of egg consumption.
Their analyses showed that individuals who ate a moderate amount of eggs had higher levels of a protein in their blood called apolipoprotein A1- a building-block of high-density lipoprotein (HDL). These individuals especially had more large, protective HDL molecules in their blood.
The researchers further identified 14 metabolites linked to heart disease, and participants who ate fewer eggs had lower levels of beneficial metabolites and higher levels of harmful ones in their blood, compared to regular egg eaters.
“Together, our results provide a potential explanation for how eating a moderate amount of eggs can help protect against heart disease,” says author Canqing Yu, Associate Professor at the Department of Epidemiology and Biostatistics, Peking University. “More studies are needed to verify the causal roles that lipid metabolites play in the association between egg consumption and the risk of cardiovascular disease.”
“This study may also have implications for Chinese national dietary guidelines,” adds senior author Liming Li, Boya Distinguished Professor at the Department of Epidemiology and Biostatistics, Peking University. “Current health guidelines in China suggest eating one egg a day, but data indicate that the average consumption is lower than this. Our work highlights the need for more strategies to encourage moderate egg consumption among the population, to help lower the overall risk of cardiovascular disease.”
A ground-breaking study into the effects of COVID on ICU patients in has confirmed evidence that the virus is associated with impaired function of the right side of the heart.
According to the study investigations, these findings could play a vital role in not only saving the lives of COVID patients, but also help in treating potentially fatal heart and lung issues generally. The findings will also help preparations for any possible future pandemic.
The first of its kind, the COVID-RV study aimed to help improve future care and outcomes for those most at risk from COVID, by gaining a better understanding of the impact the virus has on the sickest patients who require invasive ventilation.
The study was carried out in 10 ICUs across Scotland, examining 121 critically ill patients who were receiving treatment on ventilators due to the impact of SARS-CoV-2 on their system.
The findings revealed that about a third of the patients in the study showed evidence of abnormalities in the right side of the heart – the area that pumps blood to the lungs.
The study’s lead author Dr Philip McCall said that “A combination of factors create the perfect storm for COVID” to damage the right side of the heart, with possibly fatal outcomes as the lungs are unwilling to receive blood due to the infection.
“This is a very difficult condition to spot, unless you are specifically looking for it. That is why the results of this study are so important. We now know that COVID is a problem associated with not just ventilation, but can affect the heart.”
Chief Investigator of the study Dr Ben Shelley said: “The study has revealed that there is no doubt COVID affects the heart and has a major impact on outcomes for the patient.
“However, now that we know this actually happens, and have a better understanding of how it affects people, we can plan for the future and put in place new care plans and treatments to help combat this.
“For example, ultrasound scans can be used differently to focus in on early warning signs and areas we now know to be at risk.
“If we are able to see these warning signs early enough, clinicians can explore the causes of any complications and start new treatments as soon as possible, potentially improving outcomes for the sickest COVID patients.
“This kind of knowledge is invaluable, not only in combatting any future waves of COVID but in planning for future pandemics to allow people to be treated more effectively. These findings also have several fascinating areas which could be expanded on to help care for other lung conditions in general.”
Nearly half of ventilated patients in the study (47%) died because of COVID, a figure that is comparable to national and international death rates. Experts leading the COVID-RV study from NHS Golden Jubilee said that the overall condition of a person’s heart can have a significant impact on how seriously you will be affected by the potentially deadly virus.
Findings from new research published in Diabetes, Obesity and Metablismsuggest that people with type 2 diabetes may need to reduce their blood sugar levels sooner after diagnosis than previously thought, to prevent major cardiovascular events such as heart attacks.
The University of Surrey study Surrey suggests that achieving glycaemic control within the first year of diagnosis reduces the incidence of major cardiovascular events. Additionally, the team found that the greater the variation in blood levels 12-months after diagnosis, the more likely a patient was to experience dangerous cardiovascular events.
Dr Martin Whyte, co-author of the study and Reader in Metabolic Medicine at the University of Surrey, said: “The conventional wisdom has been to slowly and steadily treat type 2 diabetes with diet and medicine dose-escalation over years – the period over which it took people to reduce their sugar levels after diagnosis was thought less important for major vascular protection. However, our observational study suggests that getting blood levels under control quickly — within the first 12 months after diagnosis — will significantly help reduce cardiovascular events.”
Type 2 diabetes is a common condition that results in the level of sugar in the blood becoming too high. The condition is linked to obesity or a family history of type 2 diabetes and can increase a person’s risk of getting serious health conditions.
The University of Surrey’s study used Royal College of General Practitioners’ Research and Surveillance Centre database to perform a comprehensive examination of glycaemic control achieved within the first year of diagnosis and subsequent blood sugar level variability with cardiovascular disease incidents.
Vascular endothelial cells use a vast network of connections to control all cardiovascular functions, and failures in this network contribute to the risk of developing cardiovascular disease, according to a new study published in PNAS.
It has long been known that the development of these conditions begins with changes in the vascular endothelial cells lining the body’s blood vessels. But why and how changes in endothelial cell function occur is not entirely clear.
Research has revealed that these cells communicate with each other using a sophisticated system. Failures in this communication system may be the first step in the development of cardiovascular disease.
The endothelium, which forms the thin inner layer of cells in blood vessels, regulates blood flow, blood pressure, blood clotting, inflammation and response to disease. On a continual basis, it processes the vast amounts of information held in the composition of blood, and chemicals in the area around each blood vessel to keep the cardiovascular system working properly.
The study identified clusters of cells in the endothelium that are specialised to particular functions and they operate in ‘cliques’. Between cliques, numerous interlinked connections act to convey information, with a high density of connections to protect the system against communication failures. The system bypasses neighbouring cells by use of shortcuts to transmit information quickly over distance.
The endothelial communication network design is in fact remarkably similar to the communication operations of the internet and it is effective for local blood vessel control and global efficiency in determining overall cardiovascular activity. The design is robust, so that communication systems to control cardiovascular activity will not fail even when there is extensive damage.
The findings also indicate that changes in the organisation of communication, rather than behaviour and function of individual cells, may underlie disease.
The researchers addressed the nature of the communication network by using single-cell calcium ion imaging across thousands of endothelial cells in intact blood vessels and applying mathematical network (graph) theory.
Professor John McCarron at Strathclude University said: “Cells in the endothelium are a major target for the control of cardiovascular disease and are often treated as being a uniform population of cells. Our findings show the cells are not uniform but specialised to particular types of function.
“There is a well-organised, rapid and robust communication system that shares information so that co-ordinated responses occur. The communication system offers new targets for therapy development and insights into why developing treatments has proven so difficult.”
The US Preventive Services Task Force (USPSTF) has issued a recommendation statement on the use of aspirin in the prevention of cardiovascular disease (CVD). The recommendation shifts the use of aspirin to an earlier window, and making it an individualised decision for people in their 40s to 50s with a > 10% 10-year CVD risk.
The previous recommendation from 2016had called for low-dose aspirin for people in their 50s with a > 10% 10-year CVD risk and individualised decisions for those in their 60s with similar risk. The update comes after new evidence emergedin a number of randomised controlled trials.
For the update, which appears in JAMA Network, a systematic review was conducted on the effectiveness of aspirin to reduce the risk of CVD events (myocardial infarction and stroke), cardiovascular mortality, and all-cause mortality in persons without a history of CVD. The effect of aspirin use on colorectal cancer incidence and mortality was also investigated in primary CVD prevention populations, as well as the harms (particularly bleeding) associated with aspirin use.
The USPSTF concludes with moderate certainty that aspirin use for the primary prevention of CVD events in adults aged 40–59 years with a 10% or greater 10-year CVD risk has a small net benefit, and starting low-dose aspirin use for CVD prevention should be an individual decision for them. Those not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit. The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults 60 years or older.
Aspirin’s mechanism of action in CVD protection is well known. Aspirin at low doses is an irreversible cyclooxygenase 1 (COX-1) enzyme inhibitor, and at higher doses, it also inhibits COX-2. By inhibiting platelet function through COX-1, aspirin reduces atherothrombosis risk, and has been used widely for the prevention of CVD events, particularly for secondary prevention. However the COX-1 is also involved with protection of the gastrointestinal mucosa, and inhibition of it can promote gastrointestinal bleeding. The mechanism for the possible antineoplastic effects of aspirin is not as well understood.
Older age is one of the strongest risk factors for CVD, and men have a higher overall CVD disease burden and tend to experience CVD events earlier in life. Race and ethnicity affects CVD burden, with Black persons having the highest prevalence of CVD.
Similar CVD benefits appear for a low aspirin dose (≤ 100mg/d) and for all doses that have been studied in CVD prevention trials (50 to 500mg/d). A pragmatic approach would be to use 81 mg/d, which is the most commonly prescribed dose in the US.
Because CVD risk estimation is imprecise and imperfect at the individual level, the USPSTF suggests using these risk estimates as a starting point to discuss with appropriate candidates their desire for daily aspirin use. The benefits of initiating aspirin use are greater for individuals at higher risk for CVD events (eg, those with > 15% or > 20% 10-year CVD risk).
In addition to age and estimated level of CVD risk, decisions about initiating aspirin use should be based on shared decision-making between clinicians and patients about the potential benefits and harms, based on the relative values the patient places on these (reduced CVD risk vs increased bleeding and stroke risk).
Annual bleeding events in individuals without risk factors for increased bleeding (eg, history of gastrointestinal bleeding risk, history of peptic ulcer disease, or use of nonsteroidal anti-inflammatory drugs or corticosteroids) are rare, but risk for bleeding increases modestly with advancing age. For persons who have initiated aspirin use, the net benefits continue to accrue over time in the absence of a bleeding event. However, benefits shrink with advancing age because of increased bleeding risk, with modelling data suggesting stopping aspirin use around age 75.
