Tag: cardiovascular disease

A Glass of Wine Raises Atrial Fibrillation Risk

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A single glass of wine can rapidly increase the risk of atrial fibrillation, according to new research published in Annals of Internal Medicine.

The study provides the first evidence that alcohol consumption significantly increases the chance of the heart rhythm condition occurring within a few hours, and is contrary to the notion of a cardioprotective effect of alcohol.

“Contrary to a common belief that atrial fibrillation is associated with heavy alcohol consumption, it appears that even one alcohol drink may be enough to increase the risk,” said Gregory Marcus, MD, MAS, professor of medicine in the Division of Cardiology at UCSF.

“Our results show that the occurrence of atrial fibrillation might be neither random nor unpredictable,” he said. “Instead, there may be identifiable and modifiable ways of preventing an acute heart arrhythmia episode.”

Atrial fibrillation (AF) is the most common heart arrhythmia seen clinically, but until now research has largely focused on risk factors and treatments for the disease, rather than what can trigger episodes. Large studies have established that chronic alcohol consumption can be a predictor for AF, and Marcus and other scientists have demonstrated that it is linked to increased risk for a first diagnosis of atrial arrhythmias.  

The research centered on 100 patients with documented AF who consumed at least one alcoholic drink a month, but without substance use disorders, certain allergies, or changing medications.

Each participant wore an electrocardiogram (ECG) monitor for roughly four weeks, pressing a button whenever they had a standard-size alcoholic drink. They were also all fitted with a continuously recording alcohol sensor. Blood tests reflecting alcohol consumption over the previous weeks were periodically administered. Participants consumed a median of one drink per day throughout the study period.

Researchers found that an AF episode was associated with two-fold higher odds with one alcoholic drink, and three-fold higher odds with two or more drinks within the preceding four hours. Increased blood alcohol concentration was also associated with AF episodes.

Study limitations included patients possibly forgetting to press their monitor buttons or minimising the number of button presses due to embarrassment, although these considerations would not have affected alcohol sensor readings. The study was also limited to those with established AF, not to the general population.

“The effects seem to be fairly linear: the more alcohol consumed, the higher the risk of an acute AF event,” said Prof Marcus. “These observations mirror what has been reported by patients for decades, but this is the first objective, measurable evidence that a modifiable exposure may acutely influence the chance that an AF episode will occur.”

Source: University of California – San Francisco

When Damaged Hearts Struggle to Heal

Photo from Olivier Collett on Unsplash
Photo from Olivier Collett on Unsplash

By analysing a certain protein that forms new blood vessels following a heart attack or unstable angina the long term-survival of heart patients could be predicted.

The study, published in PLOS ONE, has shown the presence or absence of a gene variant for the protein (vascular endothelial growth factor [VEGF]-A) can help predict the long-term survival chances in males who have experienced an acute coronary event.

Dr Barry Palmer of the Massey University School of Health Sciences said that the human body’s ability to recover from severe health events such as heart attacks is aided by its capacity for new blood vessel creation.

“Measuring an individual’s ability to restore blood circulation after a serious, life-threatening health event, may be useful in choosing treatment options and timing of specialist or GP visits. It may also have implications for susceptibility to other complex diseases, such as cancer.

“We showed testing for a VEGF-A gene variant from a patient’s blood was a useful predictor of how long these patients survived after their heart disease event. This association was most obvious in non-diabetic patients.”

The study reported on 1927 patients from the Coronary Disease Cohort Study in New Zealand, of which 30 percent had at least one previous episode of serious heart disease.

In a subgroup, the researchers also investigated the utility of measuring VEGF-A protein itself from 550 heart patients.

It has long been known that VEGF-A plays a role in helping cancer tumours to grow by increasing their blood supply, Dr Palmer said.

“In the heart disease field, it’s been suggested that high levels of VEGF-A might be a good thing to help grow new blood vessels around clogging or blocked arteries. The research so far has led to some controversy with some reports showing that more VEGF-A in the bloodstream is associated with better outcome in heart disease.

“While others, including our study, show high levels of VEGF-A after a heart event is linked to worse outcomes. An explanation for this could be that high VEGF-A levels may signal hearts under stress struggling to restore heart function, but not always rescuing function enough to save badly damaged hearts,” Dr Palmer added.

“High levels of VEGF-A in the blood may be being churned out to try and grow new blood vessels in a badly damaged heart, but may not be enough for the patients with the most damaged hearts. About 40 percent more of patients with high VEGF-A are dying within eight years of their original admission to hospital.

“After adjusting for seven other relevant measurements, patients with 10-fold higher levels of VEGF-A, measured shortly after their health event, had approximately twice the risk of death during the follow-up period.”

Source: Massey University

‘Every Guideline We Write Is Out of Date’ Quips ESC as New Data Emerges

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Just as the European Society of Cardiology (ESC) unveiled their new guidelines for the treatment of heart failure, along came some data that the guideline’s authors hint will cause the work to be revised.

The guidelines, which appear in the European Heart Journal, state that so far, there is no treatment shown to reduce mortality and morbidity in patients with heart failure with preserved ejection fraction, however there are positive results from the EMPEROR-Preserved study showing that treatment with empagliflozin robustly reduced hospitalisation risk.

“Every guideline we write is out of date a few days after it’s published. I’m, of course, exaggerating a little bit, but guidelines are dynamic documents. They represent what we know at the time that they’re written and then new information comes out and they have to be updated, and that takes time,” Milton Packer, MD, of Baylor University Medical Center in Dallas, told MedPage Today.

“It’s a process, and we all understand that process; there is no real concept of finality here. We do the best we can with the data we have. And so these guidelines coming won’t represent the results of the EMPEROR-Preserved trial, but the next one will,” Dr Packer added.

Carlos Aguiar, MD, of Hospital Santa Cruz in Lisbon, agreed: “We also know that these new indications do need to go through the regulatory authorities, so it does take some time for the whole process to be concluded.”

“We do need to wait for those approvals also from the regulatory agencies in their reviews for physicians to be able to implement this in clinical practice,” he told MedPage Today.

However, the writers of the 2021 guideline did tweak the comprehensive algorithm for the treatment of heart failure, the highlights of which include:

  • Right heart catheterisation should be considered in patients in whom heart failure is thought to be due to constrictive pericarditis, restrictive cardiomyopathy, congenital heart disease, and high-output states. It may be considered in selected patients with heart failure with preserved left ventricular ejection fraction (LVEF) to confirm the diagnosis.
  • In patients with chronic heart failure with reduced LVEF, dapagliflozin (Farxiga) or empagliflozin are recommended to reduce hospitalisation and mortality risk. As a Class I recommendation, it is based on evidence gleaned from randomised clinical trials.
  • Vericiguat (Verquvo) may be considered in patients with New York Heart Association (NYHA) class II to IV heart failure after worsening with treatment with an angiotensin inhibitor, a beta-blocker, and a mineralocorticoid receptor antagonist, to reduce the risks of cardiovascular mortality or heart failure hospitalisation.
  • For treatment of heart failure with midrange LVEF — a change in term from “mildly reduced” ejection fraction — to reduce hospitalisation and mortality risk, the guidelines suggest a number of treatments including angiotensin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and the combination agent sacubitril/valsartan but none have strong clinical trial evidence (Class IIb)  .
  • For patients with heart failure with preserved ejection fraction, the current guidelines recommend (Class I evidence) screening for and treatment of aetiologies, as well as cardiovascular and non-cardiovascular comorbidities.
  • After hospitalisation for heart failure, the guidelines recommend (Class I evidence) that patients be carefully evaluated to exclude persistent signs of congestion before discharge and to optimise oral treatment, and that evidence-based oral medical treatment be administered before discharge. An early follow-up visit is recommended at 1 to 2 weeks after discharge to assess signs of congestion and drug tolerance, and to start and/or uptitrate evidence-based therapy.
  • The SGLT2 inhibitors canagliflozin (Invokana), dapagliflozin, empagliflozin, ertugliflozin (Steglatro), and sotagliflozin are recommended in patients with heart failure and type 2 diabetes at risk of cardiovascular events to reduce hospitalisations for heart failure, major cardiovascular events, end-stage renal dysfunction, and cardiovascular death. The SGLT2 inhibitors dapagliflozin, empagliflozin, and sotagliflozin are recommended in patients with type 2 diabetes and heart failure with reduced ejection fraction (Class I evidence). The DPP-4 inhibitor saxagliptin (Onglyza) is not recommended in patients with heart failure (Class III evidence).

Source: MedPage Today

Heart Attack Survivors can Extend Healthy Lifespan

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If patients follow lifestyle advice and medications after a heart attack, it could add seven healthy years of life, according to a new study.

“Most heart attack patients remain at high risk of a second attack one year later,” explained study author Dr Tinka Van Trier of Amsterdam University Medical Centre. “Our study suggests that improving both lifestyles and medication use could lower this risk, with a gain in many years of life without a cardiovascular event.”

A previous study showed that 80–90% of the risk of a heart attack can be modified by managing factors such as smoking, unhealthy diet, abdominal obesity, inadequate physical activity, hypertension, diabetes and raised blood lipid levels. Two main strategies are used: lifestyle change and medication.

However, risk factors are rarely reduced sufficiently after a heart attack, even in programmes aiming to help patients improve their lifestyles and optimise their medication. Therefore, residual risk is high to very high in a large number of patients. Dr Van Trier said: “This study was conducted to quantify this residual risk and estimate the extent to which it could be lowered with optimal management.”

The study pooled data from 3230 patients, average age 61 and 24% women, that had a heart attack or received a stent or bypass surgery. At an average of one year after the cardiac event, 30% continued smoking, 79% were overweight, and 45% reported insufficient physical activity. Only 2% of attained treatment targets for blood pressure, LDL cholesterol, and glucose levels with 40% having hypertension and 65% having high LDL cholesterol. Preventative medication use was common: 87% used antithrombotic medications, 85% took lipid lowering drugs and 86% were on blood pressure lowering drugs.

The researchers calculated the lifetime risk of a heart attack, stroke, or death from cardiovascular disease and estimated changes in healthy years when lifestyle or medication was changed or optimised. 

The estimated average residual lifetime risk for cardiovascular disease mortality was 54%. If all targets in the model were met, this risk would drop to 21%.

Dr Van Trier said: “The findings show that despite current efforts to reduce the likelihood of new events after a heart attack, there is considerable room for improvement. Our analysis suggests that the risk of another cardiovascular event could, on average, be halved if therapies were applied or intensified. For individual patients, this would translate into gaining an average of 7.5 event-free years.”

Source: European Society of Cardiology

Drone-delivered Defibs Beat Ambulances to Cardiac Arrests

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In a unique pilot project in Sweden, drones were used to deliver defibrillators to real-life alerts of suspected cardiac arrest. The drones were dispatched in more than a fifth of the emergencies and arrived on target and ahead of the ambulance in most cases. 

”This is the first time in the world that a research group can report results from a study where drones flew defibrillators to location of real-life alerts of suspected cardiac arrest,” says lead researcher Andreas Claesson, associate professor at the Center for Resuscitation Science at the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet.

With sudden cardiac arrest, every minute counts. Currently, the odds of surviving an out-of-hospital cardiac arrest are 10 percent. However, with early CPR and a shock from an automated external defibrillator (AED), the chances of survival could reach 50-70 percent but response time needs to improve. In 2019 the median response time from alert to ambulance arrival for out-of-hospital cardiac arrest (OHCA) in Sweden was 11 minutes.  
To try and reach cardiac arrest victims sooner, researchers investigated using the rapid dispatch of drone-carried defibrillators in parallel with ambulances. Drones are already used in some countries to dispatch medicines and medical supplies to remote rural regions, The study, conducted in mid-2020 in western Sweden, describes an integrated method where emergency operators, drone pilots and air traffic control worked together to facilitate the dual response.

The drones took off in response to 12 out of 53 alerts of suspected cardiac arrest over a four-month period, successfully delivering an AED to the site in 11 of those cases. In seven of those cases, the drones arrived before the ambulance, with a median time benefit of 1 minute and 52 seconds. However, no drone-delivered defibrillators were attached to the patients before ambulances arrived.

“Even if none of the AEDs were used this time, our study shows that it is possible to use drones to transport defibrillators in a safe way and with target precision during real-life emergencies,” said first-author Sofia Schierbeck, PhD student at the Center for Resuscitation Science at the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet. “A precondition for their future use is that the dispatcher takes initiative and instructs people on site to quickly collect and attach the AED in order to help the person with cardiac arrest.”

More work is needed to increase the dispatch rate and time benefits. For instance, in 2020 the drones were grounded if it was dark, rainy or the winds were too strong. The software system was also configured to avoid routes above densely populated areas, meaning that some alerts were too far out of range.

“Since this study was completed, we have identified several areas of improvement,” Andreas Claesson said. “In April this year, we began a follow-up study with a more optimised system. In that study, we want to test if we can use the drones in more alerts and reduce the response time further and thereby increase the time benefit as compared to the ambulance. Every minute without treatment in the early stages reduces the chance of survival by around 10 percent, and that is why we believe this new method of delivery has the potential to save lives.”

The results are published in the European Heart Journal.

Source: Karolinska Institute

Periodontitis Linked to Risk of Cardiovascular Disease

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A new study has found that periodontitis is associated with an increased risk of cardiovascular disease: the more severe the periodontitis, the higher the risk. Those who had a previous heart attack showed an even stronger association.

Study author Dr Giulia Ferrannini of the Karolinska Institute said: “Our study suggests that dental screening programmes including regular check-ups and education on proper dental hygiene may help to prevent first and subsequent heart events.”

Periodontitis, a disease of the tissue surrounding the tooth structure, has been associated with a number of diseases. The Swedish PAROKRANK (Periodontitis and its Relation to Coronary Artery Disease) study previously demonstrated that there was a significantly higher prevalence of periodontitis in first time heart attack patients compared to their healthy peers.

In this long-term follow-up of PAROKRANK, participants investigated whether the periodontitis, both in heart attack patients and their healthy peers, was related to an increased risk of new cardiovascular events over time.

The analysis included 1587 participants aged an average of 62 years. Participants underwent a dental examination between 2010 and 2014: 985 were classified as healthy, 489 had moderate periodontitis, and 113 had severe periodontitis. Participants were followed up for the occurrence of cardiovascular events and death. The primary endpoint was a composite of all-cause death, non-fatal heart attack or stroke, or severe heart failure. Follow-up data were collected until the end of 2018 from Swedish national death and patient registries.

Over an average 6.2 years of follow-up, there were 205 primary endpoint events. In the overall cohort, participants with periodontitis at baseline had 49% higher odds of the primary endpoint compared to those with healthy gums, increasing with periodontitis severity.
Assessing heart attack patients and healthy controls separately, graded relationship between gum disease severity and the primary endpoint was significant only for the patients group.

Dr Ferrannini said: “The risk of experiencing a cardiovascular event during follow-up was higher in participants with periodontitis, increasing in parallel with the severity. This was particularly apparent in patients who had already experienced a myocardial infarction.”

She added: “We postulate that the damage of periodontal tissues in people with gum disease may facilitate the transfer of germs into the bloodstream. This could accelerate harmful changes to the blood vessels and/or enhance systemic inflammation that is harmful to the vessels.”

“It is important to underline that the quality of care in Sweden is high, as confirmed by the overall low number of total events during follow-up. Despite this, gum disease was linked with an elevated likelihood of cardiovascular disease or death,” Dr Ferrannini concluded.

Source: European Society of Cardiology

Stress Signal From Fat Cells Induces Protective Effect in Heart

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A stress signal sent from fat cells to the heart could be protective against obesity-induced cardiac damage, according to new research. 

This might help explain the ‘obesity paradox’, where obese individuals have better short- and medium-term cardiovascular disease prognoses compared with those who are normal weight, but have worse long-term outcomes.

“The mechanism we have identified here could be one of many that protects the heart in obesity,” said study leader Philipp E. Scherer, PhD, Professor of Internal Medicine and Cell Biology at UTSW who has long studied fat metabolism.

Study co-leader Clair Crewe, PhD, Assistant Instructor of Internal Medicine at UTSW, explained that the metabolic stress of obesity gradually makes fat tissue dysfunctional, causing shrinkage and death of its mitochondria. This unhealthy fat loses the ability to store lipids generated by excess calories in food, causing lipotoxicity and poisoning other organs. However some organs, including the heart, preemptively defend against lipotoxicity. How the heart actually senses fat’s dysfunctional state has been unknown so far.

The researchers used a genetic technique to speed the loss of mitochondrial mass and function in mice. The mice were fed a high-fat diet and became obese, and their fat cells began sending out extracellular vesicles filled with small pieces of dying mitochondria. Some of these mitochondrial snippets travelled through the bloodstream to the heart and triggered oxidative stress.

Cardiaccells produce a flood of protective antioxidant molecules to counteract this stress, and this protective backlash was so strong that when the scientists injected mice with extracellular vesicles filled with mitochondrial snippets and then induced a heart attack, the animals had significantly less damage to their hearts compared with mice that didn’t receive an injection.

Fat tissue from obese human patients showed that these cells also release mitochondria-filled extracellular vesicles.

The heart and other organs in obese individuals are eventually overwhelmed by lipotoxic effects, resulting in a number of obesity’s comorbidities. If the protective mechanism identified in this study could be artificially generated, it could result in new ways of treating obesity’s negative consequences. This might even be adapted to treat normal weight individuals.

“By better understanding the distress signal from fat,” Dr Crewe said, “we may be able to harness the mechanism to improve heart health in obese and non-obese individuals alike.”

The team’s findings were published in Cell Metabolism.

Source: UT Southwestern Medical Center

Study Evaluates Efficacy and Tolerability of Ultrafiltration

A new study evaluates the efficacy and renal tolerability of ultrafiltration in acute decompensated heart failure.

Acute decompensated heart failure (ADHF) is a life-threatening and costly disease. Controversy remains regarding the efficacy and renal tolerability of ultrafiltration for treating ADHF. This article by Yajie Liu and Xin Yuan from the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China, and published in Cardiovascular Innovations and Applications, evaluated this clinical issue.

After searching databases for relevant trials, their quality and outcomes were evaluated with the use of the risk of the bias assessment tool and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, respectively. Risk ratio and the standardised or weighted mean differences were computed and pooled with fixed-effects or random-effects models.

The 19-study meta-analysis, involving 1281 patients, found that ultrafiltration was superior to control for weight loss (1.24kg) and fluid removal (1.55L) and was associated with a significant increase in serum creatinine level compared with the control treatments (0.15 mg/dL).
No significant effects were found for serum N-terminal prohormone of brain natriuretic peptide level, length of hospital stay, all-cause mortality, or all-cause rehospitalisation in the ultrafiltration group.

Overall, the meta-analysis found that use of ultrafiltration in patients with ADHF is superior to control treatments for weight loss and fluid removal but has adverse renal effects and lacks significant effects on long-term prognosis.

Source: News-Medical.Net

Lung Fibrosis Drug Pirfenidone Shines in Heart Failure Trial

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Pirfenidone, a drug to treat lung fibrosis, has shown in early trial phases that it could also help patients who suffer from a common form of heart failure.

Trialed by University of Manchester and Manchester University NHS Foundation Trust doctors and scientists, in conjunction with Liverpool Clinical Trials Centre, pirfenidone could offer a much-needed viable treatment for heart failure with preserved ejection fraction (HFpEF). The study was published in Nature Medicine.

Just under a third of 55-year-olds will develop heart failure, and 2 to 3 of every 10 people diagnosed die within a year. In about half of patients with heart failure, the forward pumping function of the heart is normal, referred to as heart failure with preserved ejection fraction (HFpEF).

While a number of processes lead to heart failure, fibrosis of the heart muscle is thought to be an important mechanism in around half to two-thirds of patients with HFpEF and is associated with adverse outcomes.

Study leader Dr Chris Miller, National Institute for Health Research Clinician Scientist at The University of Manchester, said: “Heart failure is as devastating an illness as some of the most common cancers, however its profile is much lower and treatment options for HFpEF are very limited.

“Using cardiac MRI, we were able to select patients in whom heart scarring is important. Pirfenidone then reduced that scarring.”

Pirfenidone inhibits the biological processes involved in scar formation.

The study enrolled 94 patients with heart failure, normal forward pumping function of the heart and evidence of fluid retention, randomising half to a pirfenidone treatment group and half to placebo.

Eligible patients had cardiac MRI scanning, and those who had evidence of heart scarring, as indicated by a measurement called ‘extracellular volume’. 

A second cardiac MRI was conducted a year later to measure change in heart scarring, and researchers found that extracellular volume fell by 1.21% on average in patients who took pirfenidone compared with those receiving placebo.

“Based on data from previous studies, this amount of reduction in heart scarring could translate into a substantial reduction in rates of death and admission to hospital for heart failure, however larger trials are needed to determine this,” said Dr Miller.

Additionally, fluid retention also improved in patients taking pirfenidone compared to those receiving placebo, measured using a blood test called NT-proBNP.

Dr Miller added: “Though further investigation is required, the associated improvement in fluid retention provides support for heart scarring having a causal role in heart failure and being an effective treatment target”.

The most common side effects were nausea, insomnia and rash, which are similar to that which lung patients can experience taking the drug. The results are “exciting”, Dr Miller said, but added that further trials are needed.

Source: University of Manchester

Weight Loss Not Prioritised in Heart Patient Care

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Weight loss is given insufficient priority in the management of heart patients despite the benefits, according to a new study of over 10 000 European patients.

In overweight and obese patients with coronary heart disease, weight loss is strongly recommended to reduce the risk of another heart event by improving blood pressure and lipids levels and reducing diabetes risk. This study investigated the management of patients who were overweight or obese at the time of hospitalisation for a first or recurrent heart event such as heart attack. The researchers examined lifestyle advice received, actions taken, and the relationship between weight changes and health status.

The researchers pooled data from the EUROASPIRE IV (2012 to 2013) and EUROASPIRE V (2016 to 2017) studies, which included 10 507 patients with coronary heart disease. Patients were visited 6 to 24 months after hospitalisation for their heart event (the average gap was 16 months). The visit consisted of an interview, questionnaires and a clinical examination including weight, height and blood tests.

The study found that less than 20% had a healthy body mass index (BMI) at the time of hospitalisation for a heart event. Some 16 months later, 86% of patients who were obese during hospitalisation were still obese while 14% of overweight patients had become obese. Young women were particularly affected, with nearly half of those under 55 years being obese. Yet more than a third of obese patients reported they had not received advice on physical activity or nutrition and nearly one in five said they had not been informed that they were overweight. Half of all patients reported not receiving such advice.

Weight management proved effective, with overweight or obese patients who lost 5% or more of their body weight having significantly lower levels of hypertension, dyslipidaemia, and previously unrecognised diabetes compared to those who gained 5% or more of their body weight. However, quitting smoking was observed to result in a 1.8kg average weight gain compared to an 0.4kg average weight gain in persistent smokers.

Study author Professor Catriona Jennings of the National University of Ireland – Galway said cardiac rehabilitation programmes, which typically emphasise exercise, should give equal priority to dietary management. She said: “Weight loss is best achieved by adopting healthy eating patterns and increasing levels of physical activity and exercise. Whilst actively trying to lose weight at the same time as trying to quit smoking is not advised, adopting a cardio-protective diet and becoming more physically active has the potential to mitigate the effects of smoking cessation on weight gain in patients trying to quit. Their aim is to maintain their weight and to avoid gaining even more weight following their quit.”

“Uptake and access to cardiac rehabilitation programmes is poor with less than half of patients across Europe reporting that they completed a programme,” added Professor Jennings. “Such programmes would provide a good opportunity to support patients in addressing overweight and obesity, especially for female patients who were found to have the biggest problem with overweight and obesity in the study. Uptake and access could be improved with the use of digital technology, especially for women, who possibly are less likely to attend a programme because they have many other competing priorities, such as caring for others. There are good reasons for people to address their weight after a cardiac event – but it’s not easy and they do need help.”

The study was published in European Heart Journal – Quality of Care and Clinical Outcomes, a journal of the European Society of Cardiology (ESC).

Source: European Society of Cardiology (ESC)

Journal information: Harrison, S.L., et al. (2021) Cardiovascular risk factors, cardiovascular disease, and COVID-19: an umbrella review of systematic reviews. European Heart Journal – Quality of Care and Clinical Outcomes. doi.org/10.1093/ehjqcco/qcab029.