Cardio Buzz

Drawing a map of genes might help us predict who will get sick and when we will get sick of heart disease or cancer. And we have seen Angelina Jolie, the famous actress, going for a preventive mastectomy because she had a faulty gene for breast cancer. But Is it the inevitable destiny, or can we change it? Do genes decide who will have heart disease? Who is to be blamed for heart disease? The genes we inherit, or the environment where we grow and live?Can your good genes protect you from your unhealthy lifestyle? Can a good lifestyle buffer our faulty genes?Watch it 🎦 on YouTube Read 📖it on LinkedIn ReferencesCirculation. 2022;145:808–818. DOI: 10.1161/CIRCULATIONAHA.121.053730https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.121.053730

You probably recognize the minions. Those tiny yellow characters featured in three motion pictures. I personally love them. Capsule-like small creatures with wide eyes, blue overalls and peculiar cheerful funny laughs and squawks. And I share with them their love for bananas!Kevin, Stuart, Dave and Bob are four of the most familiar minions. Individually they are small but each one has a special talent and when they work together they can create marvelous tools and solve the most difficult problems for the film’s main character.Speaking of difficult problems, hypertension is one problem that affects billions of people. Most of us, if we live to our eighties, will become hypertensive. And the control rates are poor in the developed countries. The traditional treatment is based on giving one drug in the standard dose or combining two of those two also in standard doses to lower the blood pressure.But, how about combining four (mini doses) minions of antihypertensives in one pill! Would that pill do better than a standard dose of a single good antihypertensive?This question was tackled by a trial called QUARTET trial was presented at the ESC Congress last August then published in the Lancet last September.The trial was a multicentre, double-blind randomised, trial of 571 Australian adults with hypertension, who were untreated or receiving monotherapy. Patients were randomly assigned to either quadpill or a mono therapy. The quad pill (contained 4 medications, each in one fourth of the standard dose; irbesartan 37·5 mg instead of 150, amlodipine at 1·25 mg not 5, indapamide at 0·625 mg not 2.5, and bisoprolol at 2·5 mg not 10 or even 5) or an indistinguishable monotherapy control (irbesartan 150 mg). If blood pressure was not at target, additional medications could be added in both groups. The researchers looked at BP control, safety and tolerability a 12 weeks then 12 months. And guess who won?SBP was about 7mmHg lower in the quadpil (allow me to call it the minion group) and control rates were 30% higher compared to the monotherapy group without difference in adverse events. The better BP control was sustained at one year with minions. Significantly less patients in the minion group) required additional BP medications compared to the mono therapy groupI consider this one of the key research papers in hypertension. I can think of several future implications of this conceptNumber 1: This is a further step in combination therapies for HTN. Not just two as recommended in many guidelines. With four mini doses, multiple pathophysiologic pathways tackled in one pill; sympathetic , RAS, sodium overload, vasoconstriction in small doses with less adverse effects. This can overcome physicians inertia and improve patients adherence to treatment.Number 2: Polypill is revived. Expect to see trials combining not just several BP medications, but also with statins and aspirin. NEJM trial on polypill in socioeconomic classes, cheap, more compliance, better BP and LDL reduction.Number 3: I expect the idea may be adopted by the pharma to manufacture different doses and different combinations not only triple combinations as we currently haveNumber 4: Boost to personalized medicine. Think of the tens of permutations that could come from different doses of four medications. Maybe in the future, the local pharmacist can add tailor your minion pill combinations; more beta blocker for the young, less diuretics for an elderly...etc

Athletes also can have heart disease and can collapse in the field.
How can wearable digital devices help an athlete who has suspected arrhythmia?

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788582We are in March, a month that marks international women’s day and also mothers’ day in the middle east, some African countries, and many European countries. Speaking of women's health, we tend to focus emotionally on depression, breast cancer, and osteoporosis. Whereas in fact, cardiovascular disease is the leading cause of death in women with roughly one out of every five deaths being due to CV disease.And we are familiar with the classic risk factors for coronary artery disease are diabetes, hypertension, dyslipidemia, smoking, etc but other factors can also modify the development of atherosclerotic and thrombotic disease. Nontraditional risk factors like social background, ethnicity, race, income, education, social support, etc. And we are exposed to social stresses throughout life. But as people grow older, life changes; retirement, deaths of family members and friends, and decreasing activities of daily living. These life changes contribute to decreasing social network size. And women, particularly older ladies, tend to experience more social isolation than men because they are more likely to be widowed, live alone, and get lower incomes.Today I chose a paper published in the JAMA open last February. The paper tested the impact of two, potential social determinants of disease; namely loneliness and social isolation. And we need to differentiate the two. Social isolation is the objective measure of social interactions and relationships, loneliness is the subjective feeling of being socially isolated. The researchers looked at 57,825 healthy American ladies 65 years old and above. None of them had any coronary disease or stroke. This was part of the investigation called the women's health initiative extension II. They followed those old but healthy ladies for 8 years from 2011 until 2019They measured a social isolation index score based on marital status, living situation, and frequency of social activities. Participants answered questions about being married or not, living alone, how often do you meet family and friends or call them by phone, how frequently do you go out to religious places, cinema, eat outside or go shopping. A higher score meant worse social isolation. They also measured loneliness using a scale based on questions that reflected feelings of isolation, lack of companionship, and being left out. Again, a higher score meant more loneliness. They also looked at other variables like diabetes, depression, the level of social support, the quality of the diet, and the level of physical activity. Women with the (higher) worst loneliness scores have a 14% higher chance of cardiovascular disease. Women with worse social isolation scores also had an 18% higher chance of cardiovascular disease. So now, social isolation and loneliness can be considered risk factors for coronary artery disease. What’s the explanation? Over time, the experiences of social isolation and feelings of loneliness disturb autonomic function, increase systolic blood pressure control, and evoke an inflammatory response. These may lead to hypertension and atherosclerosis. The study has limitations, of course. It was just an observational study. But it highlights the need for further research to evaluate the effectiveness of whatever interventions to reduce social isolation and loneliness and see if they can mitigate CVD risk or not. But what we are sure of is that we need to measure social isolation and loneliness in primary care. Maybe we also need to increase referrals for mental health assessments which can be done aided by AI. But the bottom line is loneliness and social isolation are bad for your mothers’ heart. So, no matter what, don’t leave your mom alone!

We all know that heart disease is the number 1 killer worldwide. And patients die either because of acute coronary syndromes (myocardial infarction) or because of left ventricular dysfunction (heart failure). And, as an interventionist, being trapped with both evils; severe coronary stenosis and left ventricular dysfunction is scary. The only solution then is usually revascularization but it also comes with risks of myocardial injury and impaired organ perfusion. There is already an entire system with bypass surgery that perfuses the organs while the heart is paralyzed, the bypass machine. Unfortunately, surgery is not always available, many patients refuse surgery, and others may be declined by the surgeons because of their high risk. Here, cath interventions are the only hope. In addition to the gadgets available to handle the coronary occlusions, there is a need for devices to support the circulation and blood pressure during cardiogenic shock or when the heart is stunned during complex coronary intervention. The last thing we want is to have a patient crashing on-table or shortly after.And to review these devices that support the heart and the circulation in complex PCI (I call them the guardian in the cath lab), I am glad to host today one of the International experts on complex coronary interventions and mechanical circulatory support. Dr. Lorenzo Azzalini. Dr. Azzalini is the Director of the Complex Coronary Interventions Program and associate professor of medicine at Virginia Commonwealth University, in Richmond, VA. Before joining VCU he was co-director of the chronic total occlusion program at San Raffaele Hospital in Milan, Italy. And San Rafaelle was one of the centers of excellence in Europe. Dr. Azzalini’s clinical and research expertise is represented by chronic total occlusion PCI, atherectomy, mechanical circulatory support, and acute kidney injury after PCI. He has over 170 international publications, more than 3700 citations, has received numerous international awards, is a member of the editorial board of the Canadian Journal of Cardiology, Eurointervention, Cardiovascular Revascularization Medicine, and Minerva Cardiology and Angiology, and is a guest reviewer for other twenty journals. And he is a wiz inside the cath lab. I had the chance to work with him several times in the cath lab and I would describe his skills as amazing.