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Importance: Synthetic nicotine is increasingly used in e-cigarette liquids along with flavors to appeal to youths. Regulatory loopholes have allowed tobacco manufacturers to use social media to target youths. Objective: To analyze the extent to which synthetic nicotine e-cigarette brands have implemented US Food and Drug Administration (FDA) health warning requirements and to evaluate the association between health warnings and user engagement on Instagram. Design, Setting, and Participants: In this cross-sectional study, posts from 25 brands were analyzed across a 14-month period (August 2021 to October 2022). A content analysis was paired with Warning Label Multi-Layer Image Identification, a computer vision algorithm designed to detect the presence of health warnings and whether the detected health warning complied with FDA guidelines by (1) appearing on the upper portion of the advertisement and (2) occupying at least 20% of the advertisement's area. Data analysis was performed from March to June 2024. Exposure: Synthetic nicotine e-cigarette advertisement on Instagram. Main Outcomes and Measures: The outcome variables were user engagement (number of likes and comments). Negative binomial regression analyses were used to evaluate the association between the presence and characteristics of health warnings and user engagement. Results: Of a total of 2071 posts, only 263 (13%) complied with both FDA health warning requirements. Among 924 posts with health warnings, 732 (79%) displayed warnings in the upper image portion, and 270 (29%) had a warning covering at least 20% of the pixel area. Posts with warnings received fewer comments than posts without warnings (mean [SD], 1.8 [2.5] vs 5.4 [11.7] comments; adjusted incident rate ratio [aIRR], 0.70; 95% CI, 0.57-0.86; P < .001). For posts containing warnings, a larger percentage of the warning label's pixel area was associated with fewer comments (aIRR, 0.96; 95% CI, 0.93-0.99; P = .003). Flavored posts with health warnings placed in the upper image portion received more likes than posts with warnings in the lower portion (mean [SD], 34.6 [35.2] vs 19.9 [19.2] likes; aIRR, 1.48; 95% CI, 1.07-2.06; P = .02). Conclusions and Relevance: In this cross-sectional study of synthetic nicotine brand Instagram accounts, 87% of sampled posts did not adhere to FDA health warning requirements in tobacco promotions. Enforcement of FDA compliant health warnings on social media may reduce youth engagement with tobacco marketing.

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Publicidad , Sistemas Electrónicos de Liberación de Nicotina , Etiquetado de Productos , Medios de Comunicación Sociales , Humanos , Estudios Transversales , Estados Unidos , Publicidad/métodos , Etiquetado de Productos/métodos , Nicotina/efectos adversos , United States Food and Drug Administration

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Background: Exhaled carbon monoxide (eCO) is associated with subclinical and overt cardiovascular disease and stroke. The association between eCO with left atrial size, prevalent, or incident atrial fibrillation (AF) are uncertain. Methods: eCO was measured using an Ecolyzer instrument among Framingham Heart Study Offspring and Omni participants who attended an examination from 1994 to 1998. We analyzed multivariable-adjusted (current smoking, and other covariates including age, race, sex, height, weight, systolic blood pressure, diastolic blood pressure, diabetes, hypertension treatment, prevalent myocardial infarction [MI], and prevalent heart failure [HF]). Cox and logistic regression models assessed the relations between eCO and incident AF (primary model), and prevalent AF and left atrial (LA) size (pre-specified secondary analyses). We also conducted secondary analyses adjusting for biomarkers, and interim MI and interim HF. Results: Our study sample included 3814 participants (mean age 58 ± 10 years; 54.4 % women, 88.4 % White). During an average of 18.8 ± 6.5 years follow-up, 683 participants were diagnosed with AF. eCO was associated with incident AF after adjusting for established AF risk factors (HR, 1.31 [95 % CI, 1.09-1.58]). In secondary analyses the association remained significant after additionally adjusting for C-reactive protein and B-type natriuretic peptide, and interim MI and CHF, and in analyses excluding individuals who currently smoked. eCO was not significantly associated with LA size and prevalent AF. Conclusion: In our community-based sample of individuals without AF, higher mean eCO concentrations were associated with incident AF. Further investigation is needed to explore the biological mechanisms linking eCO with AF.

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The importance of social drivers of health (SDOH) in the occurrence, detection, treatment, and outcome of atrial fibrillation (AF) has attracted increasing attention. Addressing SDOH factors may suggest opportunities to prevent AF and its complications. We aimed to conduct a structured narrative review and summarize current knowledge on the association between race and ethnicity, SDOH, including rural vs. urban habitation, education, income, and neighbourhood, and the risk of AF, its management, and complications. We identified 537 references in PubMed and 473 references in Embase. After removal of duplicates, we screened the abstracts of 975 references, resulting in 113 references that were examined for eligibility. Subsequently, 34 references were excluded leaving 79 references for the review. Evidence of a social gradient in AF incidence and prevelance were conflicting. However, we found substantial evidence indicating social inequities in the detection of AF, access to treatment, and outcomes such as healthcare utilization, bleeding, heart failure, stroke, dementia, work disability, and death. Inequities are reported across various health care systems and constitute a global problem affecting several continents, although data from Africa and South America are lacking. Given the documented social inequities in AF detection, management, and outcomes, there is an urgent need for healthcare systems, policymakers, and society to identify and implement effective interventions that can reduce inequities and improve outcomes in individuals with AF.

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BACKGROUND AND AIMS: This study assessed whether a model incorporating clinical features and a polygenic score for ascending aortic diameter would improve diameter estimation and prediction of adverse thoracic aortic events over clinical features alone. METHODS: Aortic diameter estimation models were built with a 1.1 million-variant polygenic score (AORTA Gene) and without it. Models were validated internally in 4394 UK Biobank participants and externally in 5469 individuals from Mass General Brigham (MGB) Biobank, 1298 from the Framingham Heart Study (FHS), and 610 from All of Us. Model fit for adverse thoracic aortic events was compared in 401 453 UK Biobank and 164 789 All of Us participants. RESULTS: AORTA Gene explained more of the variance in thoracic aortic diameter compared to clinical factors alone: 39.5% (95% confidence interval 37.3%-41.8%) vs. 29.3% (27.0%-31.5%) in UK Biobank, 36.5% (34.4%-38.5%) vs. 32.5% (30.4%-34.5%) in MGB, 41.8% (37.7%-45.9%) vs. 33.0% (28.9%-37.2%) in FHS, and 34.9% (28.8%-41.0%) vs. 28.9% (22.9%-35.0%) in All of Us. AORTA Gene had a greater area under the receiver operating characteristic curve for identifying diameter ≥ 4 cm: 0.836 vs. 0.776 (P < .0001) in UK Biobank, 0.808 vs. 0.767 in MGB (P < .0001), 0.856 vs. 0.818 in FHS (P < .0001), and 0.827 vs. 0.791 (P = .0078) in All of Us. AORTA Gene was more informative for adverse thoracic aortic events in UK Biobank (P = .0042) and All of Us (P = .049). CONCLUSIONS: A comprehensive model incorporating polygenic information and clinical risk factors explained 34.9%-41.8% of the variation in ascending aortic diameter, improving the identification of ascending aortic dilation and adverse thoracic aortic events compared to clinical risk factors.

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INTRODUCTION: Concerns exist of women underrepresentation in atrial fibrillation (AF) studies, potentially limiting the generalisability of study findings to women with AF. We assessed the participation of women in AF clinical studies performed at a tertiary care centre in the Northern Netherlands. METHODS: Eight AF clinical studies with screening logs were available for analysis. To identify sex-specific differences, patient inclusion and exclusion and reasons for exclusion were assessed. Participation-to-prevalence ratios (PPRs) were calculated to evaluate the representation of women in the studies relative to the AF sex distribution of the general population in the Netherlands (2019 Global Burden of Disease study). RESULTS: We included 1739 screened patients with AF in the analysis, of whom 722 (41.5%) were women. Of the patients screened, 161 (9%) were enrolled. Median age of screened patients was 69 years (interquartile range (IQR): 61-77), and women were older than men (71 years; IQR: 63-79 vs 68 years; IQR: 60-75; p < 0.001). Women were not underscreened compared with men (PPR: 1.09; 95% confidence interval (CI): 1.08-1.10), disproportionally excluded (92% vs 90%; p = 0.10) or less willing to participate (17% vs 15%; p = 0.36). Women had an overall PPR of 1.05 (95% CI: 1.05-1.06) compared with the general AF population. CONCLUSION: At our tertiary hospital in the Northern Netherlands, women appeared to be well-represented in AF studies. The current study advocates for the adoption of a more comprehensive measure of equity, such as the PPR, and screening log evaluation to improve the generalisability of study findings to the entire clinical AF population.

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Background: Disorders affecting cardiac conduction are associated with substantial morbidity. Understanding the epidemiology and risk factors for conduction disorders may enable earlier diagnosis and preventive efforts. Objectives: The purpose of this study was to quantify contemporary frequency and risk factors for electrocardiogram (ECG)-defined cardiac conduction disorders in a large multi-institutional primary care sample. Methods: We quantified prevalence and incidence of conduction disorders among adults receiving longitudinal primary care between 2001 and 2019, each with at least one 12-lead ECG performed prior to the start of follow-up and at least one ECG during follow-up. We defined conduction disorders using curated terms extracted from ECG diagnostic statements by cardiologists. We grouped conduction disorders by inferred anatomic location of abnormal conduction. We tested associations between clinical factors and incident conduction disease using multivariable proportional hazards regression. Results: We analyzed 189,163 individuals (median age 55 years; 58% female). The overall prevalence of conduction disorders was 27% among men and 15% among women. Among 119,926 individuals (median age 55 years; 51% female), 6,802 developed an incident conduction system abnormality over a median of 10 years (Q1, Q3: 6, 15 years) of follow-up. Incident conduction disorders were more common in men (8.78 events/1,000 person-years) vs women (4.34 events/1,000 person-years, P < 0.05). In multivariable models, clinical factors including older age (HR: 1.25 per 5-year increase [95% CI: 1.24-1.26]) and myocardial infarction (HR: 1.39 [95% CI: 1.26-1.54]) were associated with incident conduction disorders. Conclusions: Cardiac conduction disorders are common in a primary care population, especially among older individuals with cardiovascular risk factors.

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Atrial fibrillation (AF) is a globally prevalent cardiac arrhythmia with significant genetic underpinnings, as highlighted by recent large-scale genetic studies. A prominent clinical and genetic overlap exists between AF, heritable ventricular cardiomyopathies, and arrhythmia syndromes, underlining the potential of AF as an early indicator of severe ventricular disease in younger individuals. Indeed, several recent studies have demonstrated meaningful yields of rare pathogenic variants among early-onset AF patients (∼4%-11%), most notably for cardiomyopathy genes in which rare variants are considered clinically actionable. Genetic testing thus presents a promising opportunity to identify monogenetic defects linked to AF and inherited cardiac conditions, such as cardiomyopathy, and may contribute to prognosis and management in early-onset AF patients. A first step towards recognizing this monogenic contribution was taken with the Class IIb recommendation for genetic testing in AF patients aged 45 years or younger by the 2023 American College of Cardiology/American Heart Association guidelines for AF. By identifying pathogenic genetic variants known to underlie inherited cardiomyopathies and arrhythmia syndromes, a personalized care pathway can be developed, encompassing more tailored screening, cascade testing, and potentially genotype-informed prognosis and preventive measures. However, this can only be ensured by frameworks that are developed and supported by all stakeholders. Ambiguity in test results such as variants of uncertain significance remain a major challenge and as many as ∼60% of people with early-onset AF might carry such variants. Patient education (including pretest counselling), training of genetic teams, selection of high-confidence genes, and careful reporting are strategies to mitigate this. Further challenges to implementation include financial barriers, insurability issues, workforce limitations, and the need for standardized definitions in a fast-moving field. Moreover, the prevailing genetic evidence largely rests on European descent populations, underscoring the need for diverse research cohorts and international collaboration. Embracing these challenges and the potential of genetic testing may improve AF care. However, further research-mechanistic, translational, and clinical-is urgently needed.

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Edad de Inicio , Fibrilación Atrial , Pruebas Genéticas , Humanos , Fibrilación Atrial/genética , Fibrilación Atrial/diagnóstico , Pruebas Genéticas/métodos , Predisposición Genética a la Enfermedad/genética , Persona de Mediana Edad , Cardiomiopatías/genética , Cardiomiopatías/diagnóstico , Adulto

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BACKGROUND: Step counting is comparable among many research-grade and consumer-grade accelerometers in laboratory settings. OBJECTIVE: The purpose of this study was to compare the agreement between Actical and Apple Watch step-counting in a community setting. METHODS: Among Third Generation Framingham Heart Study participants (N=3486), we examined the agreement of step-counting between those who wore a consumer-grade accelerometer (Apple Watch Series 0) and a research-grade accelerometer (Actical) on the same days. Secondarily, we examined the agreement during each hour when both devices were worn to account for differences in wear time between devices. RESULTS: We studied 523 participants (n=3223 person-days, mean age 51.7, SD 8.9 years; women: n=298, 57.0%). Between devices, we observed modest correlation (intraclass correlation [ICC] 0.56, 95% CI 0.54-0.59), poor continuous agreement (29.7%, n=957 of days having steps counts with ≤15% difference), a mean difference of 499 steps per day higher count by Actical, and wide limits of agreement, roughly ±9000 steps per day. However, devices showed stronger agreement in identifying who meets various steps per day thresholds (eg, at 8000 steps per day, kappa coefficient=0.49), for which devices were concordant for 74.8% (n=391) of participants. In secondary analyses, in the hours during which both devices were worn (n=456 participants, n=18,760 person-hours), the correlation was much stronger (ICC 0.86, 95% CI 0.85-0.86), but continuous agreement remained poor (27.3%, n=5115 of hours having step counts with ≤15% difference) between devices and was slightly worse for those with mobility limitations or obesity. CONCLUSIONS: Our investigation suggests poor overall agreement between steps counted by the Actical device and those counted by the Apple Watch device, with stronger agreement in discriminating who meets certain step thresholds. The impact of these challenges may be minimized if accelerometers are used by individuals to determine whether they are meeting physical activity guidelines or tracking step counts. It is also possible that some of the limitations of these older accelerometers may be improved in newer devices.

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BACKGROUND: Life-threatening, space-occupying mass effect due to cerebral edema and/or hemorrhagic transformation is an early complication of patients with middle cerebral artery stroke. Little is known about longitudinal trajectories of laboratory and vital signs leading up to radiographic and clinical deterioration related to this mass effect. METHODS: We curated a retrospective data set of 635 patients with large middle cerebral artery stroke totaling 95,463 data points for 10 longitudinal covariates and 40 time-independent covariates. We assessed trajectories of the 10 longitudinal variables during the 72 h preceding three outcomes representative of life-threatening mass effect: midline shift ≥ 5 mm, pineal gland shift (PGS) > 4 mm, and decompressive hemicraniectomy (DHC). We used a "backward-looking" trajectory approach. Patients were aligned based on outcome occurrence time and the trajectory of each variable was assessed before that outcome by accounting for cases and noncases, adjusting for confounders. We evaluated longitudinal trajectories with Cox proportional time-dependent regression. RESULTS: Of 635 patients, 49.0% were female, and the mean age was 69 years. Thirty five percent of patients had midline shift ≥ 5 mm, 24.3% of patients had PGS > 4 mm, and 10.7% of patients underwent DHC. Backward-looking trajectories showed mild increases in white blood cell count (10-11 K/UL within 72 h), temperature (up to half a degree within 24 h), and sodium levels (1-3 mEq/L within 24 h) before the three outcomes of interest. We also observed a decrease in heart rate (75-65 beats per minute) 24 h before DHC. We found a significant association between increased white blood cell count with PGS > 4 mm (hazard ratio 1.05, p value 0.007). CONCLUSIONS: Longitudinal profiling adjusted for confounders demonstrated that white blood cell count, temperature, and sodium levels appear to increase before radiographic and clinical indicators of space-occupying mass effect. These findings will inform the development of multivariable dynamic risk models to aid prediction of life-threatening, space-occupying mass effect.

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BACKGROUND: Resting heart rate (HR) and routine physical activity are associated with cardiorespiratory fitness levels. Commercial smartwatches permit remote HR monitoring and step count recording in real-world settings over long periods of time, but the relationship between smartwatch-measured HR and daily steps to cardiorespiratory fitness remains incompletely characterized in the community. OBJECTIVE: This study aimed to examine the association of nonactive HR and daily steps measured by a smartwatch with a multidimensional fitness assessment via cardiopulmonary exercise testing (CPET) among participants in the electronic Framingham Heart Study. METHODS: Electronic Framingham Heart Study participants were enrolled in a research examination (2016-2019) and provided with a study smartwatch that collected longitudinal HR and physical activity data for up to 3 years. At the same examination, the participants underwent CPET on a cycle ergometer. Multivariable linear models were used to test the association of CPET indices with nonactive HR and daily steps from the smartwatch. RESULTS: We included 662 participants (mean age 53, SD 9 years; n=391, 59% women, n=599, 91% White; mean nonactive HR 73, SD 6 beats per minute) with a median of 1836 (IQR 889-3559) HR records and a median of 128 (IQR 65-227) watch-wearing days for each individual. In multivariable-adjusted models, lower nonactive HR and higher daily steps were associated with higher peak oxygen uptake (VO2), % predicted peak VO2, and VO2 at the ventilatory anaerobic threshold, with false discovery rate (FDR)-adjusted P values <.001 for all. Reductions of 2.4 beats per minute in nonactive HR, or increases of nearly 1000 daily steps, corresponded to a 1.3 mL/kg/min higher peak VO2. In addition, ventilatory efficiency (VE/VCO2; FDR-adjusted P=.009), % predicted maximum HR (FDR-adjusted P<.001), and systolic blood pressure-to-workload slope (FDR-adjusted P=.01) were associated with nonactive HR but not associated with daily steps. CONCLUSIONS: Our findings suggest that smartwatch-based assessments are associated with a broad array of cardiorespiratory fitness responses in the community, including measures of global fitness (peak VO2), ventilatory efficiency, and blood pressure response to exercise. Metrics captured by wearable devices offer a valuable opportunity to use extensive data on health factors and behaviors to provide a window into individual cardiovascular fitness levels.

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Capacidad Cardiovascular , Ejercicio Físico , Frecuencia Cardíaca , Humanos , Frecuencia Cardíaca/fisiología , Femenino , Masculino , Capacidad Cardiovascular/fisiología , Persona de Mediana Edad , Ejercicio Físico/fisiología , Estudios de Cohortes , Adulto , Prueba de Esfuerzo/métodos , Prueba de Esfuerzo/instrumentación , Dispositivos Electrónicos Vestibles

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Función Ventricular Izquierda , Femenino , Humanos , Masculino , Fenómenos Biomecánicos , Factores Sexuales , Volumen Sistólico/fisiología , Disfunción Ventricular Izquierda/fisiopatología , Disfunción Ventricular Izquierda/diagnóstico , Función Ventricular Izquierda/fisiología

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Inflammation biomarkers can provide valuable insight into the role of inflammatory processes in many diseases and conditions. Sequencing based analyses of such biomarkers can also serve as an exemplar of the genetic architecture of quantitative traits. To evaluate the biological insight, which can be provided by a multi-ancestry, whole-genome based association study, we performed a comprehensive analysis of 21 inflammation biomarkers from up to 38 465 individuals with whole-genome sequencing from the Trans-Omics for Precision Medicine (TOPMed) program (with varying sample size by trait, where the minimum sample size was n = 737 for MMP-1). We identified 22 distinct single-variant associations across 6 traits-E-selectin, intercellular adhesion molecule 1, interleukin-6, lipoprotein-associated phospholipase A2 activity and mass, and P-selectin-that remained significant after conditioning on previously identified associations for these inflammatory biomarkers. We further expanded upon known biomarker associations by pairing the single-variant analysis with a rare variant set-based analysis that further identified 19 significant rare variant set-based associations with 5 traits. These signals were distinct from both significant single variant association signals within TOPMed and genetic signals observed in prior studies, demonstrating the complementary value of performing both single and rare variant analyses when analyzing quantitative traits. We also confirm several previously reported signals from semi-quantitative proteomics platforms. Many of these signals demonstrate the extensive allelic heterogeneity and ancestry-differentiated variant-trait associations common for inflammation biomarkers, a characteristic we hypothesize will be increasingly observed with well-powered, large-scale analyses of complex traits.

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Biomarcadores , Estudio de Asociación del Genoma Completo , Inflamación , Medicina de Precisión , Secuenciación Completa del Genoma , Humanos , Medicina de Precisión/métodos , Inflamación/genética , Estudio de Asociación del Genoma Completo/métodos , Secuenciación Completa del Genoma/métodos , Polimorfismo de Nucleótido Simple , Sitios de Carácter Cuantitativo , Predisposición Genética a la Enfermedad , Femenino , Interleucina-6/genética

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Background: Depressive symptoms are common and share many biopsychosocial mechanisms with hypertension. Association studies between depressive symptoms and blood pressure (BP) have been inconsistent. Home BP monitoring may provide insight. Objective: To investigate the association between depressive symptoms and digital home BP. Methods: Electronic Framingham Heart Study (eFHS) participants were invited to obtain a smartphone app and digital BP cuff at research exam 3 (2016-2019). Participants with ≥3 weeks of home BP measurements within 1 year were included. Depressive symptoms were measured using the Center for Epidemiological Studies Depression Scale (CES-D). Multivariable linear mixed models were used to test the associations of continuous CES-D score and dichotomous depressive symptoms (CES-D ≥16) (independent) with home BP (dependent), adjusting for age, sex, cohort, number of weeks since baseline, lifestyle factors, diabetes, and cardiovascular disease. Results: Among 883 participants (mean age 54 years, 59% women, 91% White), the median CES-D score was 4. Depressive symptom prevalence was 7.6%. Mean systolic and diastolic BP at exam 3 were 119 and 76 mm Hg; hypertension prevalence was 48%. A 1 SD higher CES-D score was associated with 0.9 (95% CI: 0.18-1.56, P = .01) and 0.6 (95% CI: 0.06-1.07, P = .03) mm Hg higher home systolic BP and diastolic BP, respectively. Dichotomous depressive symptoms were not significantly associated with home BP (P > .2). Conclusion: Depressive symptoms were not associated with clinically substantive levels of home BP. The association between depression and cardiovascular disease risk factors warrants more data, which may be supported by mobile health measures.

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This systematic review evaluates health messaging strategies for the prevention and cessation of e-cigarette use among youth and young adults. Health messaging strategies were defined as the strategic process of developing messages with the intent to shape, reinforce, or change recipients' health attitudes and behaviors. McGuire's Communication/Persuasion Model guided the analysis of the messaging strategies, focusing on the model's five communication inputs (i.e. source, message, channel, audience, destination) and 14 persuasive outcomes. Nine databases were searched from January 2007 to September 2023. The inclusion criteria encompassed studies in English that presented quantitative data on messaging strategies aimed at discouraging vaping among youth and young adults. Each study was also coded for study characteristics and the utilization of theory. Out of 6,045 studies, 25 met the inclusion criteria. The reviewed studies exhibit a diverse array of research methods and a consistent integration of theories. The review emphasizes the nuanced main and interaction effects of various communication inputs, such as message features and audience characteristics, while also pointing out a research gap in message sources. In addition, the utilization of social media for effective messaging to engage the audience requires further research. Only one study specifically evaluated messaging strategies for vaping cessation. More research is imperative to develop targeted and tailored messages that effectively prevent and reduce vaping, especially among populations at higher risk of vaping-related harms, while also leveraging effective channels and innovative communication technologies to engage the audience.

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Historically, investigators have not differentiated between patients with and without hemorrhagic transformation (HT) in large core ischemic stroke at risk for life-threatening mass effect (LTME) from cerebral edema. Our objective was to determine whether LTME occurs faster in those with HT compared to those without. We conducted a two-center retrospective study of patients with ≥ 1/2 MCA territory infarct between 2006 and 2021. We tested the association of time-to-LTME and HT subtype (parenchymal, petechial) using Cox regression, controlling for age, mean arterial pressure, glucose, tissue plasminogen activator, mechanical thrombectomy, National Institute of Health Stroke Scale, antiplatelets, anticoagulation, temperature, and stroke side. Secondary and exploratory outcomes included mass effect-related death, all-cause death, disposition, and decompressive hemicraniectomy. Of 840 patients, 358 (42.6%) had no HT, 403 (48.0%) patients had petechial HT, and 79 (9.4%) patients had parenchymal HT. LTME occurred in 317 (37.7%) and 100 (11.9%) had mass effect-related deaths. Parenchymal (HR 8.24, 95% CI 5.46-12.42, p < 0.01) and petechial HT (HR 2.47, 95% CI 1.92-3.17, p < 0.01) were significantly associated with time-to-LTME and mass effect-related death. Understanding different risk factors and sequelae of mass effect with and without HT is critical for informed clinical decisions.

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Hospitalización , Infarto de la Arteria Cerebral Media , Humanos , Femenino , Masculino , Anciano , Estudios Retrospectivos , Persona de Mediana Edad , Infarto de la Arteria Cerebral Media/complicaciones , Hemorragia Cerebral/etiología , Hemorragia Cerebral/mortalidad , Hemorragia Cerebral/complicaciones , Edema Encefálico/etiología , Factores de Riesgo , Accidente Cerebrovascular Isquémico/mortalidad

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Background/Objective: Space occupying cerebral edema is the most feared early complication after large ischemic stroke, occurring in up to 30% of patients with middle cerebral artery (MCA) occlusion, and is reported to peak 2-4 days after injury. Little is known about the factors and outcomes associated with peak edema timing, especially when it occurs after 96 hours. We aimed to characterize differences between patients who experienced maximum midline shift (MLS) or decompressive hemicraniectomy (DHC) in the acute (<48 hours), average (48-96 hours), and subacute (>96 hours) groups and determine whether patients with subacute peak edema timing have improved discharge dispositions. Methods: We performed a two-center, retrospective study of patients with ≥1/2 MCA territory infarct and MLS. We constructed a multivariable model to test the association of subacute peak edema and favorable discharge disposition, adjusting for age, admission Alberta Stroke Program Early CT Score (ASPECTS), National Institute of Health Stroke Scale (NIHSS), acute thrombolytic intervention, cerebral atrophy, maximum MLS, parenchymal hemorrhagic transformation, DHC, and osmotic therapy receipt. Results: Of 321 eligible patients with MLS, 32%, 36%, and 32% experienced acute, average, and subacute peak edema. Subacute peak edema was significantly associated with higher odds of favorable discharge than non-subacute swelling, adjusting for confounders (aOR, 1.85; 95% CI, 1.05-3.31). Conclusions: Subacute peak edema after large MCA stroke is associated with better discharge disposition compared to earlier peak edema courses. Understanding how the timing of cerebral edema affects risk of unfavorable discharge has important implications for treatment decisions and prognostication.

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Importance: Identification of individuals at high risk for atherosclerotic cardiovascular disease within the population is important to inform primary prevention strategies. Objective: To evaluate the prognostic value of routinely available cardiovascular biomarkers when added to established risk factors. Design, Setting, and Participants: Individual-level analysis including data on cardiovascular biomarkers from 28 general population-based cohorts from 12 countries and 4 continents with assessments by participant age. The median follow-up was 11.8 years. Exposure: Measurement of high-sensitivity cardiac troponin I, high-sensitivity cardiac troponin T, N-terminal pro-B-type natriuretic peptide, B-type natriuretic peptide, or high-sensitivity C-reactive protein. Main Outcomes and Measures: The primary outcome was incident atherosclerotic cardiovascular disease, which included all fatal and nonfatal events. The secondary outcomes were all-cause mortality, heart failure, ischemic stroke, and myocardial infarction. Subdistribution hazard ratios (HRs) for the association of biomarkers and outcomes were calculated after adjustment for established risk factors. The additional predictive value of the biomarkers was assessed using the C statistic and reclassification analyses. Results: The analyses included 164 054 individuals (median age, 53.1 years [IQR, 42.7-62.9 years] and 52.4% were women). There were 17 211 incident atherosclerotic cardiovascular disease events. All biomarkers were significantly associated with incident atherosclerotic cardiovascular disease (subdistribution HR per 1-SD change, 1.13 [95% CI, 1.11-1.16] for high-sensitivity cardiac troponin I; 1.18 [95% CI, 1.12-1.23] for high-sensitivity cardiac troponin T; 1.21 [95% CI, 1.18-1.24] for N-terminal pro-B-type natriuretic peptide; 1.14 [95% CI, 1.08-1.22] for B-type natriuretic peptide; and 1.14 [95% CI, 1.12-1.16] for high-sensitivity C-reactive protein) and all secondary outcomes. The addition of each single biomarker to a model that included established risk factors improved the C statistic. For 10-year incident atherosclerotic cardiovascular disease in younger people (aged <65 years), the combination of high-sensitivity cardiac troponin I, N-terminal pro-B-type natriuretic peptide, and high-sensitivity C-reactive protein resulted in a C statistic improvement from 0.812 (95% CI, 0.8021-0.8208) to 0.8194 (95% CI, 0.8089-0.8277). The combination of these biomarkers also improved reclassification compared with the conventional model. Improvements in risk prediction were most pronounced for the secondary outcomes of heart failure and all-cause mortality. The incremental value of biomarkers was greater in people aged 65 years or older vs younger people. Conclusions and Relevance: Cardiovascular biomarkers were strongly associated with fatal and nonfatal cardiovascular events and mortality. The addition of biomarkers to established risk factors led to only a small improvement in risk prediction metrics for atherosclerotic cardiovascular disease, but was more favorable for heart failure and mortality.

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Biomarcadores , Enfermedades Cardiovasculares , Péptido Natriurético Encefálico , Fragmentos de Péptidos , Troponina I , Troponina T , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Aterosclerosis/sangre , Biomarcadores/sangre , Proteína C-Reactiva/análisis , Enfermedades Cardiovasculares/mortalidad , Enfermedades Cardiovasculares/sangre , Enfermedades Cardiovasculares/epidemiología , Estudios de Cohortes , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/mortalidad , Infarto del Miocardio/epidemiología , Infarto del Miocardio/sangre , Péptido Natriurético Encefálico/sangre , Fragmentos de Péptidos/sangre , Valor Predictivo de las Pruebas , Pronóstico , Factores de Riesgo , Troponina I/sangre , Troponina T/sangre , Internacionalidad

RESUMEN

BACKGROUND: Arterial stiffening may contribute to the pathogenesis of metabolic dysfunction-associated steatotic liver disease. We aimed to assess relations of vascular hemodynamic measures with measures of hepatic steatosis and fibrosis in the community. METHODS: Our sample was drawn from the Framingham Offspring, New Offspring Spouse, Third Generation, Omni-1, and Omni-2 cohorts (N=3875; mean age, 56 years; 54% women). We used vibration-controlled transient elastography to assess controlled attenuation parameter and liver stiffness measurements as measures of liver steatosis and liver fibrosis, respectively. We assessed noninvasive vascular hemodynamics using arterial tonometry. We assessed cross-sectional relations of vascular hemodynamic measures with continuous and dichotomous measures of hepatic steatosis and fibrosis using multivariable linear and logistic regression. RESULTS: In multivariable models adjusting for cardiometabolic risk factors, higher carotid-femoral pulse wave velocity (estimated ß per SD, 0.05 [95% CI, 0.01-0.09]; P=0.003), but not forward pressure wave amplitude and central pulse pressure, was associated with more liver steatosis (higher controlled attenuation parameter). Additionally, higher carotid-femoral pulse wave velocity (ß=0.11 [95% CI, 0.07-0.15]; P<0.001), forward pressure wave amplitude (ß=0.05 [95% CI, 0.01-0.09]; P=0.01), and central pulse pressure (ß=0.05 [95% CI, 0.01-0.09]; P=0.01) were associated with more hepatic fibrosis (higher liver stiffness measurement). Associations were more prominent among men and among participants with obesity, diabetes, and metabolic syndrome (interaction P values, <0.001-0.04). Higher carotid-femoral pulse wave velocity, but not forward pressure wave amplitude and central pulse pressure, was associated with higher odds of hepatic steatosis (odds ratio, 1.16 [95% CI, 1.02-1.31]; P=0.02) and fibrosis (odds ratio, 1.40 [95% CI, 1.19-1.64]; P<0.001). CONCLUSIONS: Elevated aortic stiffness and pressure pulsatility may contribute to hepatic steatosis and fibrosis.

Asunto(s)

Enfermedades de la Aorta , Presión Arterial , Hígado Graso , Cirrosis Hepática , Rigidez Vascular , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Hígado Graso/complicaciones , Cirrosis Hepática/complicaciones , Estudios Longitudinales , Enfermedades de la Aorta/complicaciones , Estudios Transversales

RESUMEN

BACKGROUND: Individuals with both atrial fibrillation (AF) and myocardial infarction (MI) have higher mortality compared with individuals with only 1 condition. Whether mortality differs according to the temporal order of AF and MI is unclear. METHODS AND RESULTS: We included participants from the FHS (Framingham Heart Study) from 1960 and onwards. We assessed the hazard ratio (HR) of new-onset AF and MI, and mortality according to MI and AF status (prevalent and interim) using multivariable-adjusted Cox proportional hazards models. Interim diseases were modeled as time-varying variables. For the analysis of new-onset AF, 10 923 participants (55% women; mean±SD age, 54±8 years) were included. For new-onset MI, 10 804 participants (55% women; mean±SD age, 54±8 years) were included. Compared with no MI, the hazard of new-onset AF was higher in participants with prevalent (HR, 1.60 [95% CI, 1.32-1.94]) and interim MI (HR, 3.96 [95% CI, 3.18-4.91]). Both ST-segment-elevation MI and non-ST-segment-elevation MI were associated with new-onset AF. Interim AF, not prevalent AF, was associated with higher hazard rate of new-onset MI (HR, 2.21 [95% CI, 1.67-2.92]). Interim AF was associated with both ST-segment-elevation MI and non-ST-segment-elevation MI. Mortality was significantly greater among participants with AF and MI compared with participants with 1 of the 2, regardless of temporal order. CONCLUSIONS: We report a bidirectional association between AF and MI, which was observed for both non-ST-segment-elevation MI and ST-segment-elevation MI. Participants with both AF and MI had considerably higher mortality compared with participants with only 1 of the 2 conditions, regardless of order.

Asunto(s)

Fibrilación Atrial , Humanos , Fibrilación Atrial/mortalidad , Fibrilación Atrial/epidemiología , Fibrilación Atrial/complicaciones , Femenino , Persona de Mediana Edad , Masculino , Anciano , Factores de Riesgo , Factores de Tiempo , Prevalencia , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/epidemiología , Infarto del Miocardio sin Elevación del ST/mortalidad , Infarto del Miocardio sin Elevación del ST/diagnóstico , Infarto del Miocardio sin Elevación del ST/epidemiología , Medición de Riesgo/métodos , Infarto del Miocardio/mortalidad , Infarto del Miocardio/epidemiología , Massachusetts/epidemiología , Modelos de Riesgos Proporcionales , Pronóstico

RESUMEN

BACKGROUND: Short-term blood pressure variability (BPV) is associated with arterial stiffness in patients with hypertension. Few studies have examined associations between arterial stiffness and digital home BPV over a mid- to long-term time span, irrespective of underlying hypertension. OBJECTIVE: This study aims to investigate if arterial stiffness traits were associated with subsequent mid- to long-term home BPV in the electronic Framingham Heart Study (eFHS). We hypothesized that higher arterial stiffness was associated with higher home BPV over up to 1-year follow-up. METHODS: At a Framingham Heart Study research examination (2016-2019), participants underwent arterial tonometry to acquire measures of arterial stiffness (carotid-femoral pulse wave velocity [CFPWV]; forward pressure wave amplitude [FWA]) and wave reflection (reflection coefficient [RC]). Participants who agreed to enroll in eFHS were provided with a digital blood pressure (BP) cuff to measure home BP weekly over up to 1-year follow-up. Participants with less than 3 weeks of BP readings were excluded. Linear regression models were used to examine associations of arterial measures with average real variability (ARV) of week-to-week home systolic (SBP) and diastolic (DBP) BP adjusting for important covariates. We obtained ARV as an average of the absolute differences of consecutive home BP measurements. ARV considers not only the dispersion of the BP readings around the mean but also the order of BP readings. In addition, ARV is more sensitive to measurement-to-measurement BPV compared with traditional BPV measures. RESULTS: Among 857 eFHS participants (mean age 54, SD 9 years; 508/857, 59% women; mean SBP/DBP 119/76 mm Hg; 405/857, 47% hypertension), 1 SD increment in FWA was associated with 0.16 (95% CI 0.09-0.23) SD increments in ARV of home SBP and 0.08 (95% CI 0.01-0.15) SD increments in ARV of home DBP; 1 SD increment in RC was associated with 0.14 (95% CI 0.07-0.22) SD increments in ARV of home SBP and 0.11 (95% CI 0.04-0.19) SD increments in ARV of home DBP. After adjusting for important covariates, there was no significant association between CFPWV and ARV of home SBP, and similarly, no significant association existed between CFPWV and ARV of home DBP (P>.05). CONCLUSIONS: In eFHS, higher FWA and RC were associated with higher mid- to long-term ARV of week-to-week home SBP and DBP over 1-year follow-up in individuals across the BP spectrum. Our findings suggest that higher aortic stiffness and wave reflection are associated with higher week-to-week variation of BP in a home-based setting over a mid- to long-term time span.