Objective Studies investigating the impact of chocolate consumption on cardiovascular disease (CVD) have reached inconsistent conclusions. As such, a quantitative assessment of the dose-response association between chocolate consumption and incident CVD has not been reported. We performed a systematic review and meta-analysis of studies assessing the risk of CVD with chocolate consumption. Methods PubMed and EMBASE databases were searched for articles published up to 6 June 2018. Restricted cubic splines were used to model the dose-response association. Results Fourteen publications (23 studies including 405 304 participants and 35 093 cases of CVD) were included in the meta-analysis. The summary of relative risk (RR) per 20 g/week increase in chocolate consumption was 0.982 (95% CI 0.972 to 0.992, I-2=50.4%, n=18) for CVD (heart failure: 0.995 (0.981 to 1.010, I-2=36.3%, n=5); total stroke: 0.956 (0.932 to 0.980, I-2=25.5%, n=7); cerebral infarction: 0.952 (0.917 to 0.988, I-2=0.0%, n=4); haemorrhagic stroke: 0.931 (0.871 to 0.994, I-2=0.0%, n=4); myocardial infarction: 0.981 (0.964 to 0.997, I-2=0.0%, n=3); coronary heart disease: 0.986 (0.973 to 0.999, n=1)). A non-linear dose-response (p(non-linearity)=0.001) indicated that the most appropriate dose of chocolate consumption for reducing risk of CVD was 45 g/week (RR 0.890;95%CI 0.849 to 0.932). Conclusions Chocolate consumption may be associated with reduced risk of CVD at
Objectives His bundle pacing (HBP) can potentially correct left bundle branch block (LBBB). We aimed to assess the efficacy of HBP to correct LBBB and long-term clinical outcomes with HBP in patients with heart failure (HF). Methods This is an observational study of patients with HF with typical LBBB who were indicated for pacing therapy and were consecutively enrolled from one centre. Permanent HBP leads were implanted if the LBBB correction threshold was <3.5V/0.5 ms or 3.0 V/1.0 ms. Pacing parameters, left ventricular ejection fraction (LVEF), left ventricular end-systolic volume (LVESV) and New York Heart Association (NYHA) Class were assessed during follow-up. Results In 74 enrolled patients (69.6 +/- 9.2 years and 43 men), LBBB correction was acutely achieved in 72 (97.3%) patients, and 56 (75.7%) patients received permanent HBP (pHBP) while 18 patients did not receive permanent HBP (non-permanent HBP), due to no LBBB correction (n=2), high LBBB correction thresholds (n=10) and fixation failure (n=6). The median follow-up period of pHBP was 37.1 (range 15.0-48.7) months. Thirty patients with pHBP had completed 3-year follow-up, with LVEF increased from baseline 32.4 +/- 8.9% to 55.9 +/- 10.7% (p<0.001), LVESV decreased from a baseline of 137.9 +/- 64.1 mL to 52.4 +/- 32.6 mL (p<0.001) and NYHA Class improvement from baseline 2.73 +/- 0.58 to 1.03 +/- 0.18 (p<0.001). LBBB correction threshold remained stable with acute threshold of 2.13 +/- 1.19 V/0.5 ms to 2.29 +/- 0.92 V/0.5 ms at 3-year follow-up (p>0.05). Conclusions pHBP improved LVEF, LVESV and NYHA Class in patients with HF with typical LBBB.
Objective To assess the association between educational attainment and acute myocardial infarction (AMI) outcomes in China to inform future healthcare interventions. Methods We used data from the China Patient-centred Evaluative Assessment of Cardiac Events-Prospective AMI study of 3369 consecutive patients hospitalised with AMI from 53 hospitals. Educational attainment was categorised as: high (senior high school, college or postgraduate degree), intermediate (junior high school) or low (primary school or illiterate). We used survival models to assess the relationship between education and 1-year major adverse cardiovascular events (MACE), all-cause mortality, both unadjusted and after adjustment for demographic characteristics and cardiovascular risk factors. Results The median participant age was 61 (52, 69) years, 23.2% were women, and 33.3% had high, 32.4% intermediate and 34.3% low educational attainment. In unadjusted analysis, compared with high educational attainment, low educational attainment was associated with a higher 1-year risk of MACE (HR 2.41, 95% CI 1.72 to 3.37) and death (HR for low vs high education 3.09, 95% CI 1.69 to 5.65). In risk-adjusted analyses, the association between education and death was attenuated and no longer statistically significant (adjusted HR 1.41, 95% CI 0.74 to 2.69, p=0.30). However, the risk of 1-year MACE (adjusted HR 1.68, 95% CI 1.18 to 2.41, p=0.004) remained significantly greaterin low educational attainment group. Conclusions In a national Chinese cohort of patients hospitalised with AMI, low educational attainment was associated with a higher risk of adverse events in the year following discharge. This association highlights the need to consider interventions to improve AMI outcomes in adults with low levels of education.
Background To evaluate the effects of proprotein convertase subtilisin/kexin 9 (PCSK9) inhibitors on major adverse cardiovascular events (MACE). Methods Our systematic review included randomised controlled trials if they studied PCSK9 inhibitors in patients for primary and/or secondary prevention of cardiovascular diseases or with hypercholesterolaemia/hyperlipidaemia. Dichotomous variables from individual studies were pooled by relative risks (RR) and their 95% CIs using the random-effect model. Risk difference (RD) in the 10-year frame was also estimated using the pooled RR and the estimated baseline risk using the control group. Grading of Recommendation Assessment, Development and Evaluation was used to assess the quality of evidence. Results We included 54 trials with 97 910 patients in the analysis. Compared with controls, PCSK9 inhibitors significantly reduced the risk of MACE by 16% (RR, 0.84; 95% CI 0.79 to 0.89; RD: 47 fewer per 1000 vs 286 as the baseline risk; 95% CI 32 to 59 fewer), non-fatal myocardial infarction (MI) by 17% (RR, 0.83; 95% CI 0.74 to 0.93; RD, 35 fewer per 1000 vs 207 as the baseline; 95% CI 13 to 53 fewer) and any stroke by 25% (RR, 0.75; 95% CI 0.65 to 0.85; RD, 16 fewer per 1000 vs 61 as the baseline; 95% CI 9 to 21 fewer) with moderate quality evidence. No significant differences were found between PCSK9 inhibitors and control groups in all-cause mortality, cardiovascular death, heart failure or unstable angina with low-quality evidence. Conclusions This study demonstrated that PCSK9 inhibitors could significantly reduce the risk of MACE, non-fatal MI and stroke.
Objective To assess the association of metformin prescription with the risk of aortic aneurysm, aortic aneurysm events and the enlargement of abdominal aortic aneurysm (AAA). Design Systematic review and meta-analysis. Methods We searched PubMed, Embase and Scopus for epidemiological studies up to November 2018. We included observational studies which evaluated the association of metformin prescription with the risk of aortic aneurysm disease, and we also included studies involving progression and enlargement of AAA. The Newcastle-Ottawa Scale was used to assess the quality of included studies. Random-effect meta-analyses were conducted in line with the between-study heterogeneity. Sensitivity analyses were performed to identify the source of heterogeneity. Results Eight studies enrolling 29 587 participants met the inclusion criteria and were included in this systematic review. We found that metformin prescription could significantly limit the enlargement of aortic aneurysm (weighted mean difference: -0.83 mm/year, 95% CI -1.38 to -0.28, I-2=89.6%) among patients with AAA. Metformin prescription status may be associated with a decreased risk of aortic aneurysm and aortic aneurysm events. Conclusions According to the available epidemiological evidence, metformin prescription could limit the expansion of AAA among patients with this disease, and may be involved with a lower incidence of aortic aneurysm and aortic aneurysm events. Randomised controlled trials are needed to confirm whether metformin could reduce the enlargement of AAA in patients with or without diabetes.
Objective The time needed to increase oxygen utilisation to meet metabolic demand (V?O-2 kinetics) is impaired in heart failure (HF) with reduced ejection fraction and is an independent risk factor for HF mortality. It is not known if V?O-2 kinetics are slowed in HF with preserved ejection fraction (HFpEF). We tested the hypothesis that V?O-2 kinetics are slowed during submaximal exercise in HFpEF and that slower V?O-2 kinetics are related to impaired peripheral oxygen extraction. Methods Eighteen HFpEF patients (68 +/- 7 years, 10 women) and 18 healthy controls (69 +/- 6 years, 10 women) completed submaximal and peak exercise testing. Cardiac output (acetylene rebreathing, Q?(c)), ventilatory oxygen uptake (V?O-2, Douglas bags) and arterial-venous O-2 difference (a-vO(2) difference) derived from Q?(c) and V?O-2 were assessed during exercise. Breath-by-breath O-2 uptake was measured continuously throughout submaximal exercise, and V?O-2 kinetics was quantified as mean response time (MRT). Results HFpEF patients had markedly slowed V?O-2 kinetics during submaximal exercise (MRT: control: 40.1 +/- 14.2, HFpEF: 65.4 +/- 27.7 s; p<0.002), despite no relative impairment in submaximal cardiac output (Q?(c): control: 8.6 +/- 1.7, HFpEF: 9.7 +/- 2.2 L/min; p=0.79). When stratified by MRT, HFpEF with an MRT >= 60 s demonstrated elevated Q?(c), and impaired peripheral oxygen extraction that was apparent during submaximal exercise compared with HFpEF with a MRT <60 s (submaximal a-vO(2) difference: MRT <60 s: 9.7 +/- 2.1, MRT >= 60 s: 7.9 +/- 1.1 mL/100 mL; p=0.03). Conclusion HFpEF patients have slowed V?O-2 kinetics that are related to impaired peripheral oxygen utilisation. MRT can identify HFpEF patients with peripheral limitations to submaximal exercise capacity and may be a target for therapeutic intervention.
Background A number of studies have demonstrated a J-shaped curve between blood pressure (BP) and all-cause mortality, but few studies have used longitudinal change in BP to study mortality in the Chinese population. Methods We performed a 30-year follow-up study to examine the association between BP (at baseline and longitudinal change) and risk of mortality in the Linxian General Population Trial Cohort. At baseline, a total of 29 584 healthy adults were enrolled in the Linxian General Population Trial in 1985 and followed through to the end of 2014. The final analysis was restricted to 29 439 participants (55% women) after exclusion of outliers. We also examined the potential effects of BP trajectory patterns during the period of 1985-1999 on sequent risk of mortality. Adjusted Cox proportional hazards models were used to estimate HRs and 95% CIs. Results Compared with participants with normal BP, patients with prehypertension, stage 1, stage 2 or stage 3 hypertension had an increased risk of all-cause mortality, with HRs of 1.09 (95% CI 1.05 to 1.14), 1.34 (95% CI 1.28 to 1.40), 1.69 (95% CI 1.60 to 1.79) and 2.14 (95% CI 2.01 to 2.28), respectively. Relative to stable BP of normotension, having a rise in BP from normotension to hypertension or from prehypertension to hypertension both conferred an increased risk of total and cardiovascular disease and stroke mortality (total: HRs 1.22 (95% CI 1.12 to 1.34) and 1.36 (95% CI 1.23 to 1.51); cardiovascular disease: HRs 1.42 (95% CI 1.17 to 1.73) and 1.55 (95% CI 1.24 to 1.93); stroke: HRs 2.29 (95% CI 1.88 to 2.80) and 2.61 (95% CI 2.11 to 3.24), respectively). Conclusions These findings emphasise that development of incident hypertension in middle age could increase the risk of total, cardiovascular disease and stroke mortality, and suggest that current BP targets could be revised.
Objective To examine the associations between egg consumption and cardiovascular disease (CVD), ischaemic heart disease (IHD), major coronary events (MCE), haemorrhagic stroke as well as ischaemic stroke. Methods During 2004-2008, over 0.5 million adults aged 30-79 years were recruited from 10 diverse survey sites in China. Participants were asked about the frequency of egg consumption and were followed up via linkages to multiple registries and active investigation. Among 461 213 participants free of prior cancer, CVD and diabetes, a total of 83 977 CVD incident cases and 9985 CVD deaths were documented, as well as 5103 MCE. Stratified Cox regression was performed to yield adjusted hazard ratios for CVD endpoints associated with egg consumption. Results At baseline, 13.1% of participants reported daily consumption (usual amount 0.76 egg/day) and 9.1% reported never or very rare consumption (usual amount 0.29 egg/day). Compared with non-consumers, daily egg consumption was associated with lower risk of CVD (HR 0.89, 95% CI 0.87 to 0.92). Corresponding multivariate-adjusted HRs (95% CI) for IHD, MCE, haemorrhagic stroke and ischaemic stroke were 0.88 (0.84 to 0.93), 0.86 (0.76 to 0.97), 0.74 (0.67 to 0.82) and 0.90 (0.85 to 0.95), respectively. There were significant dose-response relationships of egg consumption with morbidity of all CVD endpoints (P for linear trend < 0.05). Daily consumers also had an 18% lower risk of CVD death and a 28% lower risk of haemorrhagic stroke death compared to non-consumers. Conclusion A mong Chinese adults, a moderate level of egg consumption (up to < 1 egg/day) was significantly associated with lower risk of CVD, largely independent of other risk factors.
Objective To evaluate the diagnostic performance of a deep learning system for automated detection of atrial fibrillation (AF) in photoplethysmographic (PPG) pulse waveforms. Methods We trained a deep convolutional neural network (DCNN) to detect AF in 17 s PPG waveforms using a training data set of 149 048 PPG waveforms constructed from several publicly available PPG databases. The DCNN was validated using an independent test data set of 3039 smartphone-acquired PPG waveforms from adults at high risk of AF at a general outpatient clinic against ECG tracings reviewed by two cardiologists. Six established AF detectors based on handcrafted features were evaluated on the same test data set for performance comparison. Results In the validation data set (3039 PPG waveforms) consisting of three sequential PPG waveforms from 1013 participants (mean (SD) age, 68.4 (12.2) years; 46.8% men), the prevalence of AF was 2.8%. The area under the receiver operating characteristic curve (AUC) of the DCNN for AF detection was 0.997 (95% CI 0.996 to 0.999) and was significantly higher than all the other AF detectors (AUC range: 0.924-0.985). The sensitivity of the DCNN was 95.2% (95% CI 88.3% to 98.7%), specificity was 99.0% (95% CI 98.6% to 99.3%), positive predictive value (PPV) was 72.7% (95% CI 65.1% to 79.3%) and negative predictive value (NPV) was 99.9% (95% CI 99.7% to 100%) using a single 17 s PPG waveform. Using the three sequential PPG waveforms in combination (<1 min in total), the sensitivity was 100.0% (95% CI 87.7% to 100%), specificity was 99.6% (95% CI 99.0% to 99.9%), PPV was 87.5% (95% CI 72.5% to 94.9%) and NPV was 100% (95% CI 99.4% to 100%). Conclusions In this evaluation of PPG waveforms from adults screened for AF in a real-world primary care setting, the DCNN had high sensitivity, specificity, PPV and NPV for detecting AF, outperforming other state-of-the-art methods based on handcrafted features.