Cardiology — Weekly Evidence Brief

Cardiovascular disease (CVD) events, including coronary heart disease, heart failure, and stroke, are almost universally preceded by at least one nonoptimal traditional risk factor such as blood pressure, cholesterol, glucose, or smoking 1. This underscores the critical importance of robust primary prevention. In patients with type 2 diabetes (T2DM) at high risk of atherosclerotic cardiovascular disease (ASCVD), the use of evidence-based preventive therapies, including GLP-1RAs, SGLT2 inhibitors, ACEi/ARBs, statins, and aspirin, is associated with a lower risk of major adverse cardiovascular events (MACE), heart failure hospitalization, and kidney disease 2. Risk prediction models like the PREVENT equations can help guide aspirin use for primary CVD prevention, refining patient selection for these therapies 3. Machine learning models using claims and electronic health record data also show promise in identifying older adults with T2DM at higher risk of cardiovascular events, aiding in population health and research 4.

Beyond traditional risk factors, novel lipid and glucose markers are emerging as important predictors of residual cardiovascular risk. In anticoagulated atrial fibrillation (AF) patients, a high non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio (NHHR) is independently associated with an increased risk of thromboembolic events and MACE 5. Similarly, higher remnant cholesterol independently predicts all-cause death, ischemic stroke, and acute myocardial infarction in AF patients on oral anticoagulants, even when LDL-C levels are controlled 6. For patients with coronary artery disease (CAD), the Stress Hyperglycemia Ratio (SHR), integrating acute glucose and HbA1c, is significantly linked to increased long-term risks of all-cause death, cardiovascular death, and MACE 7.

The understanding and management of heart failure (HF) continue to evolve. Central adiposity, rather than hypertension, appears to be a more significant driver of heart failure with preserved ejection fraction (HFpEF) evolution and progression, with therapeutic reduction of adiposity notably reducing heart failure hospitalizations 8. Device-based therapies are integral to HF management, offering benefits beyond pharmacologic approaches, though many are underutilized in eligible patients 910. Specific hemodynamic profiles during pulmonary artery pressure sensor implantation can risk stratify patients with chronic heart failure with reduced ejection fraction (HFrEF), with 'Cold-Wet' profiles indicating a significantly increased risk of cardiac failure 11. Furthermore, heart failure in patients with sarcoidosis carries a higher 1-year mortality and readmission rate compared to other etiologies like dilated or ischemic cardiomyopathy 12. Defective calcium handling in cardiac myocytes is also identified as a central pathogenic mechanism in both heart failure and arrhythmias, suggesting a target for future therapeutics 13.

Specific therapeutic strategies are showing promise for high-risk cardiovascular populations. Trimetazidine use has been associated with a lower risk of both new-onset and recurrent ischemic stroke in patients with ischemic heart disease and atrial fibrillation 14. For individuals with type 2 diabetes and diabetic cardiomyopathy (DCM), all forms of exercise, particularly high-intensity interval training (HIIT), demonstrated beneficial effects by improving cardiac function and reducing inflammation and fibrosis 15. Moreover, monitoring cardiovascular risk trajectories over time, rather than just baseline risk, is crucial, as an accelerated CVD risk trajectory is associated with increased long-term risk of all stroke, ischemic stroke, hemorrhagic stroke, and vascular dementia 16. Finally, Long COVID (PASC) presents a significant concern with persistent cardiovascular symptoms driven by mechanisms such as immune dysregulation and endothelial dysfunction, leading to increased risks of pericarditis, cardiomyopathy, and heart failure 17.