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Socioeconomic and Structural Barriers to Addressing Obesity in Communities: A Scientific Statement From the American Heart Association
The obesity epidemic continues largely unabated, affecting more than one-third of the US population and disproportionately burdening individuals from socioeconomically disadvantaged populations. Numerous factors contribute to the high prevalence of obesity, including socioeconomic and structural barriers impeding primordial and primary prevention efforts. Despite broad recognition that social determinants of health are key drivers of obesity, the importance of socioeconomic and structural factors as contemporary barriers to individual-, community-, and population-level obesity prevention and intervention efforts remains underappreciated. This scientific statement highlights multilevel barriers to obesity prevention and management, with an emphasis on social determinants of health, societal culture, and shared biases that may interfere with the success of healthy weight management programs. The assessment includes a comprehensive review of policy and community-level strategies used to address the obesity epidemic and identifies key areas for future research.
Routine Application of Three-Dimensional Transesophageal Echocardiography-based Device Selection for Transcatheter Closure of Atrial Septal Defect without Balloon Sizing
Abstract Background There is no standardized global framework for device size selection in transcatheter atrial septal defect (ASD) closure. We aimed to evaluate outcomes and insights from routine application of a device selection strategy based on 3D transesophageal echocardiography (TEE) in consecutive patients undergoing ASD closure. Methods The study population was derived from a prospective ASD₃DDeviceSize registry, in which device sizing was exclusively determined prior to the procedure by a 3D TEE-based formula. All patients were clinically followed for a median of 1. 6 years after the procedure. Results Between September 2016 and May 2024, a total of 748 patients were included. Median procedural and fluoroscopy times were 18. 0 and 3. 7 minutes, respectively. Procedure success rate was 99. 5%. One patient (0. 1%) required intraprocedural device size reselection. Device embolization occurred in three (0. 4%) patients; two of these cases were attributed to delivery system malfunction. Device malposition was found in one (0. 1%) patient, who underwent surgery. During follow-up, one patient required surgery for cardiac erosion. Among 186 (24. 9%) oval ASDs, long axis orientations were diverse. Computational simulations demonstrated that, when balloon sizing was assumed to be performed in the fluoroscopic antero-posterior projection, the greatest underestimation of maximal diameter with a discrepancy of 34. 9% occurred in the horizontally-oriented oval ASDs Conclusions Preprocedural determination of device size based on 3D TEE provides a safe and useful framework in routine clinical practice. Because of the diversity in maximal diameter orientation, balloon sizing using a fixed fluoroscopic angle may underestimate the true maximal diameter of an ASD. (ClinicalTrials. gov number NCT 02097758)
Prediabetes, Subclinical Myocardial Injury or Stress, and Heart Failure Risk for Adults With Hypertension
Importance It is unclear whether and the extent to which subclinical myocardial injury or stress coexisting with prediabetes is associated with the risk of heart failure (HF). Objective To evaluate the joint associations of prediabetes and subclinical myocardial injury or stress with incident HF risk. Design, Setting, and Participants This post hoc prospective cohort study analyzed data from the Systolic Blood Pressure Intervention Trial (SPRINT). Two analytic samples were used: (1) adults with hypertension without diabetes or prior HF for the baseline biomarkers analysis and (2) participants with biomarker measurements at both baseline and 12 months for the longitudinal biomarkers’ change. Prediabetes was defined as a fasting plasma glucose level of 100 to 125 mg/dL. Subclinical myocardial injury was defined as a high-sensitivity cardiac troponin I (hs-cTnI) level of 6 ng/L or higher in men and 4 ng/L or higher in women and subclinical myocardial stress defined as an N-terminal pro–B-type natriuretic peptide (NT-proBNP) level of 125 pg/mL or higher. A 25% or greater increase in any biomarker concentration from baseline to 12 months defined longitudinal change. Data were analyzed between January 1 and May 31, 2025. Main Outcomes and Measures The primary outcome was adjudicated incident HF. Cox proportional hazards models were used to estimate hazard ratios (HRs) for HF across joint categories of prediabetes and biomarker elevation. Results Of 8234 participants (mean SD age, 68 9 years; 37.1% women), 3271 (39.7%) had prediabetes, 2942 (35.7%) had subclinical myocardial injury, and 3593 (43.6%) had subclinical myocardial stress. Over a median follow-up of 3.2 years (IQR, 2.8-3.8 years), 122 participants developed HF. Compared with normoglycemia and no myocardial injury, those with both prediabetes and injury had the highest HF risk (HR, 4.20; 95% CI, 2.31-7.63); similar findings were observed for myocardial stress (HR, 5.20; 95% CI, 2.52-10.70). In the longitudinal analysis (median follow-up, 2.3 years IQR, 1.9-2-8 years), 7449 participants with both prediabetes and a 25% or greater increase in hs-cTnI or NT-proBNP level had the highest risk of HF (for hs-cTnI: HR, 3.05; 95% CI, 1.58-5.88; for NT-proBNP: HR, 2.39; 95% CI, 1.28-4.46). Conclusions and Relevance These findings suggest that among adults with hypertension, prediabetes in combination with subclinical myocardial injury or stress is associated with a significantly elevated risk for HF. These findings support the integration of glycemic status and cardiac biomarkers profiling to improve HF risk stratification and guide prevention.
Elevated Resting Coronary Blood Flow Is Associated With Death, MI, and HF in All-Comer Patients With Chronic Coronary Syndrome
BACKGROUND: The prognostic implications of bolus thermodilution-derived resting coronary blood flow in all-comer patients with chronic coronary syndrome are not known. We investigated the association of thermodilution-derived indices characterizing coronary flow with outcomes. METHODS: Patients with chronic coronary syndrome with and without obstructive coronary artery disease were included before undergoing coronary angiography in this prospective observational study. Measurements of the index of microcirculatory resistance, baseline resistance index, resting coronary blood flow (CBF), and hyperemic CBF were obtained with thermodilution in the left anterior descending coronary artery. Cox-regression analyses adjusted for age, sex, number of diseased vessels, and estimated creatinine clearance, as well as Kaplan-Meier plots, were used to evaluate the relation between flow indices and the primary composite outcome of all-cause mortality, nonfatal myocardial infarction, or heart failure hospitalization. RESULTS: Analyses included 410 patients with 55 events. Median follow-up was 5.4 years. Resting CBF was independently associated with the primary outcome (hazard ratio, 1.23 95% CI 1.02–1.48). Resting CBF was associated with the primary outcome in patients undergoing revascularization (hazard ratio, 1.30 95% CI 1.04–1.64) but not in patients not undergoing revascularization (hazard ratio, 1.15 95% 0.82–1.60; P interaction=0.771). Neither the index of microcirculatory resistance nor hyperemic CBF was associated with outcomes. Functional coronary microvascular dysfunction was associated with a higher incidence of death and nonfatal myocardial infarction versus no coronary microvascular dysfunction (log-rank P =0.041), whereas structural coronary microvascular dysfunction was not. CONCLUSIONS: Elevated resting CBF in the left anterior descending coronary artery was associated with major adverse cardiovascular events in chronic coronary syndrome, whereas hyperemic microcirculatory resistance and flow were not. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT06306066.
Ketone bodies and incident heart failure: 20-year results from the prospective British Regional Heart Study
Abstract Aims Ketone bodies (KB), acetoacetate and β-hydroxybutyrate, are an important fat-derived alternative energy source for the heart and have been implicated in the pathogenesis of cardiovascular disease. The study aimed to determine the relationship between total KB (acetoacetate + β-hydroxybutyrate) and KB ratio (acetoacetate: β-hydroxybutyrate) with incident HF in older men. Methods 3459 men without prevalent myocardial infarction or HF from the prospective cohort British Regional Heart Study were included in the analysis. KB levels were measured by nuclear magnetic resonance spectroscopy. Participants were followed up for a median 15.9 years. Results 375 men developed HF. Total KB was not significantly associated with incident HF (age-adjusted standardised hazards ratio (HR) (95%CI) 0.94 0.84–1.04, p=0.231 for trend). However, KB ratio was significantly associated with incident HF (age-adjusted standardised HR (95%CI) 1.12 1.01–1.24, p=0.023 for trend). Risk tended to increase with increasing levels of KB ratio from 0.35 with risk significantly raised when the KB ratio was above 0.55 (top decile) even after adjustment for traditional cardiovascular risk factors, inflammatory markers, and NT-proBNP HR (95%CI) for KB ratio gt;0.55 vs lt;0.18 (bottom quartile) =1.60 (1.13–2.27), p=0.008. The increased risk associated with elevated KB ratio was more evident in the younger men (age lt; 70 years). When examined by levels of NT-proBNP, elevated KB ratio was significantly associated with increased HF risk only in the presence of elevated NT-proBNP (gt;83pg/ml; above the median) age-adjusted HR=1.87 (1.25-2.81). Weaker associations were seen in those without raised NT-proBNP HR=1.23 (0.66-2.27). Conclusion Elevated KB ratio is associated with a significantly increased risk of HF incidence independent of established cardiovascular risk factors and inflammatory markers. Elevated KB ratio may serve as a biomarker of HF incidence particularly when NT-proBNP is also elevated.
Fluid Restriction vs. Liberal Intake in Patients with Heart Failure: A Meta-Analysis of Randomized Trials
Meta-analysis demonstrates fluid restriction reduces mortality in heart failure patients, suggesting need for updated guidelines.
Effects of Empagliflozin on Right Ventricular Free-Wall Strain in Patients with Heart Failure and Reduced Ejection Fraction
Exploratory trial shows empagliflozin improves RV function in low RVFWS patients with HFrEF, suggesting beneficial outcomes.
Sex Differences in Spontaneous Coronary Artery Dissection: A Report of the iSCAD Registry
Background Spontaneous coronary artery dissection is a cause of myocardial infarction, which predominantly affects middle‐aged women. There are limited data on men with spontaneous coronary artery dissection. Methods Information on demographics, presenting characteristics, in‐hospital outcomes including major adverse cardiovascular events (composite of myocardial infarction, cerebrovascular accident, or heart failure), length of stay, and discharge medications in men and women were obtained from the multicenter iSCAD (International Spontaneous Coronary Artery Dissection) registry. Results Of 1252 patients enrolled from 2019 to 2023, 80 (6.4%) were men. Mean age did not significantly differ between sexes (men, 50.2±10.3 versus women 49.7±10.4; P =0.792). Women reported more emotional stress preceding spontaneous coronary artery dissection (10.2% versus 2.5% men; P =0.025). Men reported more physical stress (22.5% versus 7.7% women; P 0.001), both isometric exertion (12.5% versus 2.4% women; P 0.001) and aerobic exertion (12.5% versus 5.6% women, P 0.013). Chest discomfort was the major symptom, although women reported more non–chest discomfort, shortness of breath, and nausea/vomiting. Men had fewer autoimmune conditions, systemic inflammatory disorders, and fibromuscular dysplasia but more recreational drug use. In‐hospital major adverse cardiovascular events did not significantly differ (4.1% men versus 8.5% women; P =0.178). The median length of stay was 3.0 (interquartile range, 3.0–4.0) days for males versus 4.0 (interquartile range, 3.0–5.0) days for women ( P =0.003). At discharge, more men were prescribed statins (72.5% men versus 55.3% women; P =0.003) and dual antiplatelet therapy (66.3% men versus 53.7% women) ( P =0.049). Conclusions In a large spontaneous coronary artery dissection registry, there were significant sex differences in presentation, baseline medical conditions, and triggers. In‐hospital outcomes were similar, but length of stay was longer for women. Men were more often discharged on statins and dual antiplatelet therapy.
Cognitive Outcomes in Randomized Controlled Trials of Coronary Artery Bypass Graft Surgery From 2005 to 2025: A Systematic Review
Background Cognitive decline after coronary artery bypass graft (CABG) is common and affects morbidity, mortality, and quality of life. We systematically reviewed randomized CABG trial control arms to characterize cognitive assessments, testing frequency, attrition, and ability to detect perioperative change. Methods We searched MEDLINE, Embase, Cochrane Library, and PsycINFO for randomized controlled trials of CABG surgery that included at least one arm of patients solely undergoing CABG and that reported at least one objective cognitive assessment, from January 2005 to February 2025. Trials with mixed cardiac surgery or only subjective measures were excluded. We summarized task frequency, cognitive domains, and attrition. For tasks assessed preoperatively and postoperatively in ≥3 trials, we reported control group means and SDs. Risk of bias was assessed using the Cochrane Risk of Bias tool among 6 bias domains. This study was supported by NIH–R01NS123639. Results Of 3494 screened studies, 2284 were CABG trials, and only 71 (3.1%) reported cognitive evaluation. These involved 15 925 patients (79% men; mean age, 64.2 years; median follow‐up, 90 days) and used 145 unique cognitive tasks, with the Trail Making Test Part B (40 of 71; 56.3%) and Part A (38 of 71; 53.5%) being the most frequently administered. Among 7 tasks with sufficient data, none detected preoperative to postoperative changes. Attrition rates averaged 18.9%, with a broad range of 0 to 62%. Conclusions Cognitive assessment is uncommon in CABG trials, and commonly used tests rarely detect change. Heterogeneity precluded meta‐analysis, and high attrition raises concerns about selection and survivorship bias. To evaluate cognitive impact after CABG, trials need standardized, sensitive assessment strategies resilient to attrition and feasible for broad deployment.
A Simple Method Is Used to Identify PVI‐Responsive Patients With Persistent Atrial Fibrillation: Electrical Cardioversion and Noninduction Before Procedure
Exploratory cohort study finds identifying PVI-responsive patients enhances arrhythmia-free outcomes in persistent atrial fibrillation.