European Heart Journal

Crea, Filippo

doi: 10.1093/eurheartj/ehac311pmid: 35724980

Open in new tabDownload slide Open in new tabDownload slide With thanks to Amelia Meier-Batschelet, Johanna Huggler, and Martin Meyer for help with compilation of this article.  For the podcast associated with this article, please visit https://academic.oup.com/eurheartj/pages/Podcasts. This Focus Issue on Acute Cardiovascular Care contains the Special Article entitled ‘Data standards for acute coronary syndrome and percutaneous coronary intervention: the European Unified Registries for Heart Care Evaluation and Randomized Trials (EuroHeart)’ by Gorav Batra from Uppsala University in Sweden, and colleagues. Standardized data definitions are essential for monitoring and benchmarking the quality of care and patient outcomes in observational studies and randomized controlled trials. There are no contemporary pan-European data standards for acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI).1 The European Unified Registries for Heart Care Evaluation and Randomized Trials (EuroHeart) project of the European Society of Cardiology (ESC) aimed to develop such data standards for ACS and PCI. Following a systematic review of the literature on ACS and PCI data standards and evaluation of contemporary ACS and PCI registries, we undertook a modified Delphi process involving clinical and registry experts from 11 European countries, as well as representatives from relevant ESC Associations, including the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and Acute CardioVascular Care (ACVC). This resulted in final sets of 68 and 84 ‘mandatory’ variables and several catalogues of optional variables for ACS and PCI, respectively. Data definitions were provided for these variables, which have been programmed as the basis for continuous registration of individual patient data in the online EuroHeart IT platform. By means of a structured process and the interaction with major stakeholders, internationally harmonized data standards for ACS and PCI have been developed. In the context of the EuroHeart project, this will facilitate country-level quality of care improvement, international observational research, registry-based randomized trials, and post-marketing surveillance of devices and pharmacotherapies. Cardiac biomarkers have a strong value for diagnosis and monitoring of major cardiac diseases with the examples of high-sensitivity cardiac troponin I and high-sensitivity cardiac troponin T for ACS and B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) for heart failure.2–4 In a Viewpoint article entitled ‘Interferences with cardiac biomarker assays: understanding the clinical impact’, Arnaud Nevraumont from the Cliniques universitaires Saint-Luc and Université catholique de Louvain in Brussels, Belgium, and colleagues5 note that their main weakness remains the susceptibility to analytical interferences. Indeed, each of these tests can be impaired by interferences leading to incorrect results with potentially life-threatening consequences. The optimization of assays as well as the continuous education and communication between clinical laboratories and physicians remain key factors to limit the real threat of analytical interferences. Figure 1 Open in new tabDownload slide The performance of the GRACE (v2.0) risk score in predicting in-hospital mortality for NSTEMI by ethnicity.7 Figure 1 Open in new tabDownload slide The performance of the GRACE (v2.0) risk score in predicting in-hospital mortality for NSTEMI by ethnicity.7 The Global Registry of Acute Coronary Events (GRACE) score was developed to evaluate risk in patients with ACS with or without ST-segment elevation.6 In a Clinical Research article entitled ‘Ethnicity-dependent performance of the Global Registry of Acute Coronary Events risk score for prediction of non-ST-segment elevation myocardial infarction in-hospital mortality: nationwide cohort study’, Saadiq Moledina from Keele University in Stoke-on-Trent, UK, and colleagues indicate that little is known about its performance at predicting in-hospital mortality for ethnic minority patients.7 The authors identified 326 160 admissions with non-ST-segment elevation myocardial infarction (NSTEMI) in the Myocardial Infarction National Audit Project (MINAP), 2010–17, including White (n = 299 184) and ethnic minorities (excluding White minorities) (n = 26 976). They calculated the GRACE score for in-hospital mortality and assessed ethnic group baseline characteristics by low, intermediate, and high risk. The performance of the GRACE risk score was estimated by discrimination (area under the receiver operating characteristic curve [AUC]) and calibration (calibration plots). Ethnic minorities presented younger and had increased prevalence of cardiometabolic risk factors in all GRACE risk groups. The GRACE risk score for White (AUC 0.87) and ethnic minority (AUC 0.87) patients had good discrimination. However, whilst the GRACE risk model was well calibrated in White patients (expected to observed [E : O] in-hospital death rate ratio 0.99; slope 1.00), it overestimated risk in ethnic minority patients (E : O ratio 1.29; slope: 0.94) (Figure 1). Moledina et al. conclude that the GRACE risk score provides good discrimination overall for in-hospital mortality, but it is not well calibrated and overestimates risk for ethnic minorities with NSTEMI. The contribution is accompanied by an Editorial by François Schiele and Nicolas Meneveau from the University Hospital of Besançon in France.8 The authors of this provocative editorial highlight that we may just have to accept that a risk score for predicting mortality in ACS, however well validated, calibrated, or accurate it may be, is no longer necessary for the management of NSTEMI in the context of today's antithrombotic and interventional strategies. Figure 2 Open in new tabDownload slide P2Y12 inhibitor adherence trajectories among patients with acute coronary syndrome undergoing percutaneous coronary intervention and associations with major adverse cardiovascular events. P2Y12 inhibitor adherence trajectories and prevalence, unadjusted MACE rate by P2Y12 inhibitor trajectory, unadjusted MACE rate by P2Y12 inhibitor trajectory stratified by stent type (— drug-eluting stent, --- no drug-eluting stent). ACS, acute coronary syndrome; DES, drug-eluting stent; MACE, major adverse cardiovascular event; PCI, percutaneous coronary intervention.10 Figure 2 Open in new tabDownload slide P2Y12 inhibitor adherence trajectories among patients with acute coronary syndrome undergoing percutaneous coronary intervention and associations with major adverse cardiovascular events. P2Y12 inhibitor adherence trajectories and prevalence, unadjusted MACE rate by P2Y12 inhibitor trajectory, unadjusted MACE rate by P2Y12 inhibitor trajectory stratified by stent type (— drug-eluting stent, --- no drug-eluting stent). ACS, acute coronary syndrome; DES, drug-eluting stent; MACE, major adverse cardiovascular event; PCI, percutaneous coronary intervention.10 Double antiplatelet therapy plays a key role in the treatment of ACS.9 Post-ACS P2Y12 inhibitor non-adherence is common and associated with greater risk of major adverse cardiovascular events (MACEs). Non-adherence can follow different trajectories from an inability to initiate, implement, or continue therapy for the intended duration. In a Clinical Research article entitled ‘P2Y12 inhibitor adherence trajectories in patients with acute coronary syndrome undergoing percutaneous coronary intervention: prognostic implications’, Ricky D. Turgeon from the University of British Columbia in Vancouver, BC, Canada, and colleagues aimed to evaluate P2Y12 inhibitor adherence trajectories among ACS patients treated with PCI, their frequency, and association with MACE.10 The authors conducted a cohort study of adults discharged alive after PCI for ACS (2012–16) using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry linked with administrative data. The primary outcome was P2Y12 inhibitor adherence trajectory in the year after PCI assessed using group-based trajectory modelling. They used logistic regression and Cox proportional-hazards regression to assess associations of trajectories with risk factors and MACEs. A total of 12 844 patients were included (mean age 62 years, 24% female) and five trajectories were identified: early consistent non-adherence (11.0%), rapid decline (7.7%), delayed initiation (6.0%), gradual decline (20.5%), and persistent adherence (54.8%). Compared with persistent adherence, rapid decline (hazard ratio [HR) 1.23]) and delayed initiation (HR 1.41) were associated with higher MACE in the overall cohort, whereas early consistent non-adherence was associated with higher MACE only in the subgroup receiving a drug-eluting stent (DES) (HR 2.44) (Figure 2). Turgeon and colleagues conclude that after PCI for ACS, patients follow one of five distinct P2Y12 inhibitor adherence trajectories. Rapid decline and delayed initiation are associated with a higher risk of MACE, whereas early consistent non-adherence is only associated with higher MACE risk in patients receiving DES. This manuscript is accompanied by an Editorial by Yaling Han and Yang Li from the General Hospital of Northern Theater Command in Shenyang, China.11 The authors conclude that the data published in the article will be helpful to evaluate the trajectories of adherence to P2Y12 inhibitors among patients with ACS treated with PCI and the association with MACE, but the lack of detailed information on patients, the individualized time of P2Y12 inhibitor discontinuation, the causal relationship between bleeding and non-adherence, as well as types of P2Y12 inhibitors and DES, still call for additional large-scale registries specifically examining these points. Performing similar studies in different geographic areas may also be useful to evaluate the impact of socioeconomic factors on P2Y12 inhibitor adherence trajectories. Despite these unknowns, the present study represents a valuable contribution to the identification of five distinct trajectories of P2Y12 inhibitor adherence, risk factors for P2Y12 inhibitor non-adherence trajectories, and the association of P2Y12 inhibitor trajectory with MACE and major bleeding. Platelet activation plays a key role in the pathogenesis of ACS.12,13 Adverse cardiovascular events have day/night patterns with peaks in the morning, potentially related to endogenous circadian clock control of platelet activation. Circadian nuclear receptor Rev-erbα is an essential and negative component of the circadian clock. In a Translational Research article entitled ‘Circadian nuclear receptor Rev-erbα is expressed by platelets and potentiates platelet activation and thrombus formation, Jianfeng Shi from Shanghai Jiao Tong University in China, and colleagues point out that to date, the expression profile and biological function of Rev-erbα in platelets have never been reported.14 Here, the authors report the presence and functions of circadian nuclear receptor Rev-erbα in human and mouse platelets. Both human and mouse platelet Rev-erbα showed a circadian rhythm that positively correlated with platelet aggregation. Global Rev-erbα knockout and platelet-specific Rev-erbα knockout mice exhibited impaired haemostasis as assessed by prolonged tail-bleeding times. Rev-erbα deletion also reduced ferric chloride-induced carotid arterial occlusive thrombosis, prevented collagen/epinephrine-induced pulmonary thromboembolism, and protected against microvascular microthrombi obstruction and infarct expansion in an acute myocardial infarction model. In vitro thrombus formation assessed by CD41-labelled platelet fluorescence intensity was significantly reduced in Rev-erbα knockout mouse blood. Platelets from Rev-erbα knockout mice exhibited impaired agonist-induced aggregation responses, integrin αIIbβ3 activation, and α-granule release. Consistently, pharmacological inhibition of Rev-erbα by specific antagonists decreased platelet activation markers in both mouse and human platelets. Mechanistically, mass spectrometry and co-immunoprecipitation analyses revealed that Rev-erbα potentiated platelet activation via oligophrenin-1-mediated RhoA/ERM (ezrin/radixin/moesin) pathway. The authors conclude that they provide the first evidence that circadian protein Rev-erbα is functionally expressed in platelets and potentiates platelet activation and thrombus formation. Rev-erbα may serve as a novel therapeutic target for managing thrombosis-based cardiovascular disease. This contribution is accompanied by an Editorial by Simon Tual-Chalot and Konstantinos Stellos from Newcastle University in Newcastle upon Tyne, UK.15 The authors note that the discovery of clock elements in platelets lays the foundation for a novel chrono-pharmacological-based antiplatelet therapy to inhibit or ameliorate acute thrombotic events. Future studies are needed to ascertain the relevance of the circadian platelet clock and its target genes and explain the time-dependent onset of ACS. Tual-Chalot and Stellos believe that from now on future drug development should also consider the drug target's circadian rhythmicity and metabolism throughout the 24-hour day. The issue is also complemented by two Discussion Forum contributions. In a commentary entitled ‘An attempt to better show some results such as the comparison of mortality and major adverse cardiovascular events between the abnormal and normal coronary flow reserve cohorts’, Houyong Zhu from the Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University in China, and colleagues comment on the recent publication ‘Coronary flow reserve and cardiovascular outcomes: a systematic review and meta-analysis’ by Mihir Kelshiker from Imperial College London, UK, and colleagues.16,17 Kelshiker et al. respond in a separate comment.18 Dr. Crea reports speaker fees from Amgen, Astra Zeneca, Servier, BMS, other from GlyCardial Diagnostics, outside the submitted work. The editors hope that readers of this issue of the European Heart Journal will find it of interest. References 1 Batra G , Aktaa S, Wallentin L, Maggioni AP, Ludman P, Erlinge D, et al. Data standards for acute coronary syndrome and percutaneous coronary intervention: the European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart) . Eur Heart J 2022 ; 43 : 2269 – 2285 . Google Scholar OpenURL Placeholder Text WorldCat 2 Kotecha T , Knight DS, Razvi Y, Kumar K, Vimalesvaran K, Thornton G, et al. Patterns of myocardial injury in recovered troponin-positive COVID-19 patients assessed by cardiovascular magnetic resonance . Eur Heart J 2021 ; 42 : 1866 – 1878 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Farmakis D , Mueller C, Apple FS. High-sensitivity cardiac troponin assays for cardiovascular risk stratification in the general population . Eur Heart J 2020 ; 41 : 4050 – 4056 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Rubattu S , Volpe M. BNP level and post-transcatheter aortic valve replacement outcome: an intriguing J-shaped relationship . Eur Heart J 2020 ; 41 : 970 – 972 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Nevraumont A , Deltombe M, Favresse J, Guillaume L, Chapelle V, Twerenbold R, et al. Interferences with cardiac biomarker assays: understanding the clinical impact . Eur Heart J 2022 ; 43 : 2286 – 2288 . Google Scholar OpenURL Placeholder Text WorldCat 6 Hung J , Roos A, Kadesjö E, McAllister DA, Kimenai DM, Shah ASV, et al. Performance of the GRACE 2.0 score in patients with type 1 and type 2 myocardial infarction . Eur Heart J 2021 ; 42 : 2552 – 2561 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Moledina SM , Kontopantelis E, Wijeysundera HC, Banerjee S, Van Spall HGC, Gale CP, et al. Ethnicity-dependent performance of the Global Registry of Acute Coronary Events risk score for prediction of non-ST-segment elevation myocardial infarction in-hospital mortality: nationwide cohort study . Eur Heart J 2022 ; 43 : 2289 – 2299 . Google Scholar OpenURL Placeholder Text WorldCat 8 Schiele F , Meneveau N. NSTEMI management: a fall from GRACE? Eur Heart J 2022 ; 43 : 2300 – 2302 . Google Scholar OpenURL Placeholder Text WorldCat 9 Motovska Z , Montalescot G. The Cornelian dilemma† of quitting DAPT . Eur Heart J 2021 ; 42 : 4635 – 4637 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Turgeon RD , Koshman SL, Dong Y, Graham MM. P2Y12 inhibitor adherence trajectories in patients with acute coronary syndrome undergoing percutaneous coronary intervention: prognostic implications . Eur Heart J 2022 ; 43 : 2303 – 2313 . Google Scholar OpenURL Placeholder Text WorldCat 11 Han Y , Li Y. Adherence to P2Y12 inhibitors in acute coronary syndrome after a percutaneous coronary intervention: what can we improve? Eur Heart J 2022 ; 43 : 2314 – 2316 . Google Scholar OpenURL Placeholder Text WorldCat 12 Schnorbus B , Daiber A, Jurk K, Warnke S, Koenig J, Lackner KJ, et al. Effects of clopidogrel vs. prasugrel vs. ticagrelor on endothelial function, inflammatory parameters, and platelet function in patients with acute coronary syndrome undergoing coronary artery stenting: a randomized, blinded, parallel study . Eur Heart J 2020 ; 41 : 3144 – 3152 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Liberale L , Gorog DA. Low-grade endotoxaemia and platelets: a deadly aggregation . Eur Heart J 2020 ; 41 : 3166 – 3168 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Shi J , Tong R, Zhou M, Gao Y, Zhao Y, Chen Y, et al. Circadian nuclear receptor Rev-erbα is expressed by platelets and potentiates platelet activation and thrombus formation . Eur Heart J 2022 ; 43 : 2317 – 2334 . Google Scholar OpenURL Placeholder Text WorldCat 15 Tual-Chalot S , Stellos K. Chrono-pharmacology-based antiplatelet therapy for acute myocardial infarction . Eur Heart J 2022 ; 43 : 2335 – 2337 . Google Scholar OpenURL Placeholder Text WorldCat 16 Zhu H , Chen T, Huang J. An attempt to better show some results such as the comparison of mortality and major adverse cardiovascular events between the abnormal and normal coronary flow reserve cohorts . Eur Heart J 2022 ; 43 : 2338 – 2339 . Google Scholar OpenURL Placeholder Text WorldCat 17 Kelshiker MA , Seligman H, Howard JP, Rahman H, Foley M, Nowbar AN, et al. Coronary flow reserve and cardiovascular outcomes: a systematic review and meta-analysis . Eur Heart J 2022 ; 43 : 1582 – 1593 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Kelshiker MA , Seligman H, Howard JP, Petraco R. The importance of time-to-event analysis in measuring the prognostic impact of coronary flow reserve . Eur Heart J 2022 ; 43 : 2340 . Google Scholar Crossref Search ADS WorldCat Published by Oxford University Press on behalf of European Society of Cardiology 2022. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Published by Oxford University Press on behalf of European Society of Cardiology 2022.

Khanji, Mohammed Y; Waqar, Salman; Khawaja, Zohaib; Ali, Bismah

doi: 10.1093/eurheartj/ehac190pmid: 35441660

Introduction Early delivery of high-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation strengthen the initial links of the chain of survival and can help improve out-of-hospital cardiac arrest (OHCA) outcomes. However, health inequalities exist in OHCA survival at regional and global levels, which reduces the chances of survival, with disproportionately lower CPR delivery rates seen in areas of socio-economic deprivation and ethnic minority groups.1 In the United Kingdom for example, the British Muslim and South Asian communities also have higher levels of health disparities in cardiovascular disease, diabetes, and physical activity, which can predispose them to poorer outcomes from OHCA.2 Thus, when developing and delivering training for the public, it is important to ensure that there is equitable access. Faith-placed health programmes Faith organizations can play a vital role in addressing the needs of the public and underserved populations. Places of worship can provide ‘therapeutic landscapes’ for discussions centred around health promotion and well-being. During the COVID-19 pandemic, various faith communities across the world have promoted positive and effective public health messaging, which has transcended borders and reached groups that conventional messaging may struggle to influence.3 These communities can provide support where health infrastructure may be nascent and enable a wider public reach, especially because minority groups are thought to have a greater religious identity.4 The British Islamic Medical Association (BIMA) has developed the BIMA Lifesavers programme (www.britishima.org/lifesavers) to provide Basic Life Support (BLS) training in CPR, recovery position, and management of choking. The grassroots, volunteer-driven, and not-for-profit programme aims to utilize faith institutions, such as mosques, as centres to teach life-support skills to the public. The project has become a large public-oriented BLS teaching programme delivered in over 80 mosques across the UK, including online delivery, during the period of the COVID-19 pandemic restrictions;5 this is quite significant because it started in the year 2014 with just three mosques in East London. The work of BIMA Lifesavers has now been adapted for implementation in several countries across the world. Teaching is delivered annually on a single day and is open to all members of the public. Teaching is delivered by healthcare professional volunteers who are familiar with the needs of the local community. To widen participation, training is offered in English and other languages where needed, as many volunteers are multilingual. The mosques allow cost-free use of the venues and there is no charge for the attendees. These elements of the project have enabled increased local opportunities and simultaneously reduced cost and language barriers. An overview of the process used for planning and delivery of the programme is outlined in Figure 1. The potential benefits of delivering such a programme using places of worship, such as mosques, along with the key requirements for delivering such a programme and the potential challenges involved, are summarized in Figure 2. Figure 1 Open in new tabDownload slide Summary of the process required for planning and delivery of the BIMA Lifesavers programme. Figure 1 Open in new tabDownload slide Summary of the process required for planning and delivery of the BIMA Lifesavers programme. Figure 2 Open in new tabDownload slide Overview of key benefits, key requirements, and potential limitations or challenges of delivering a Lifesavers programme through places of worship such as a mosque. Figure 2 Open in new tabDownload slide Overview of key benefits, key requirements, and potential limitations or challenges of delivering a Lifesavers programme through places of worship such as a mosque. Team recruitment and organization Recruitment of volunteers is done through a variety of channels, including healthcare professionals and medical student networks, social media channels, email, and by word of mouth. A national team works closely with the regional teams to help with coordination and increase the efficiency of team working, project planning, engagement, and delivery. This structure facilitates innovative changes to be easily cascaded, based on feedback from volunteers and attendees, thus evolving with the needs of the community through co-production. Recruitment and engagement of the public A multi-step approach to public engagement and recruitment is used to maximize public attendance including social media, the BIMA website, and advertisements through local hospitals. Faith leaders can be influential in health behaviours, so we encourage local mosques to publicize the event through sermons during Friday prayers, displaying posters and providing short reminders after daily congregational prayers. Delivering the training The BIMA Lifesavers programme was developed based on the British Heart Foundation Heartstart programme with additional resources including from the Resuscitation Council UK (RCUK). The teaching programme covers three main areas: (i) delivery of CPR to an unconscious person who is not breathing (along with introduction to and encouraging early use of automated electronic defibrillators (AEDs), (ii) putting an unconscious person who is breathing into the recovery position, and (iii) management of a person who is choking. Each skill is taught by using a four-step technique with an initial explanation of the importance and need for learning the BLS/good quality CPR skills, whilst making it religiously and culturally relevant and easy to understand. Animations and practical videos produced by national resuscitation bodies are used along with addressing general questions and common myths surrounding BLS/CPR. Secondly, a practical demonstration is provided by the volunteers in real time, followed by breaking down the practical demonstration with explanations and answering any questions. Lastly, all participants practice the skills with interactive feedback so that they will have increased confidence and competence. On completion of the training, the participants are signposted to additional resources and training opportunities and encouraged to download volunteer alert or response apps such as GoodSAM (www.goodsamapp.org) so that volunteers can be rapidly dispatched when near a suspected OHCA. Formal feedback is requested from all participants and volunteers to facilitate improvements in future delivery followed by providing certificates of attendance. Collaborations and shared learning Collaborations with partners such as RCUK and the National Health Service, England, have become important to allow standardization and shared learning. The BIMA also supports other professional societies and groups (e.g. RCUK, St John’s Ambulance) with translation of CPR-related material into other languages, ensuring accuracy and culturally relevant material, which enables a wider reach and increases the potential impact of resources. Global expansion The BIMA Lifesavers model has now been expanded globally. In 2021, the programme was delivered across 12 other countries, including Malaysia, Kenya, Pakistan, India, Canada, and Australia. The material that is used for advertising and teaching is shared and modified to make it relevant to the local population. Conclusions A grassroot, volunteer-organized and delivered BLS training is made feasible to train the members of the public in delivering effective CPR (and early AED use), recovery position, and management of choking. Co-ordinated delivery through mosques has been successful both nationally and internationally, and a similar strategy could also be utilized and implemented through other religious institutions and places of worship. Acknowledgements We would like to thank all volunteers who supported and delivered the Lifesavers training over the years and all those who continue to teach and provide such life-saving skills. Conflict of interest: B.A. and Z.K. were the national and vice national leads, respectively, for the BIMA Lifesavers programme during the year 2021, and M.Y.K. was the public relations and collaborations lead. S.W. is the vice president of the BIMA. All roles are in a voluntary, unpaid capacity. The BIMA is an independent, not-for-profit organization offering free basic life support training to the community. References 1 Khanji MY , Chahal CAA, Ricci F, Akhter MW, Patel RS. Cardiopulmonary resuscitation training to improve out-of-hospital cardiac arrest survival: addressing potential health inequalities . Eur J Prev Cardiol 2021 ; https://doi.org/10.1093/eurjpc/zwab214. Google Scholar OpenURL Placeholder Text WorldCat 2 Suleman M , Asaria M, Haque E, Safdar M, Shafi S, Sherif J. Elderly and end of life care for Muslims in the UK . Muslim Counc Britain 2019 ; https://mcb.org.uk/wp-content/uploads/2019/08/MCB_ELC_Web.pdf. (accessed Jan 30, 2022). Google Scholar OpenURL Placeholder Text WorldCat 3 WHO . World Health Organization strategy for engaging religious leaders, faith-based organizations and faith communities in health emergencies . 2021 https://www.who.int/publications/i/item/9789240037205 (accessed Jan 30, 2022) . 4 Heath AF , Fisher SD, Rosenblatt G, Sanders D, Sobolewska M. The political integration of ethnic minorities in britain . Oxford University Press ; 2013 . Google Scholar Crossref Search ADS Google Preview WorldCat COPAC 5 Khanji MY , Ali B, Ahmed S. Virtual delivery of cardiopulmonary resuscitation training for the public: how to make it work . Eur Heart J 2021 ; 42 : 4710 – 4712 . Google Scholar Crossref Search ADS PubMed WorldCat Published by Oxford University Press on behalf of European Society of Cardiology 2022. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Cobey, Kelly D; Liu, Peter P

doi: 10.1093/eurheartj/ehac189pmid: 35511501

If we have learned anything as a biomedical research community in the past 2 years because of the COVID-19 pandemic, it is that there are major unaddressed challenges and inefficiencies in how research is traditionally conducted and disseminated. This ‘inefficiency’ in biomedical research has been documented for decades1 but the pandemic has reinvigorated discussion, and provided vivid examples of unnecessary duplication, irresponsible dissemination of flawed studies, and poor study design.2 At the start of the pandemic, the global community responded swiftly to minimize waste in COVID-19 research. The Wellcome Trust initiated a statement on sharing research data and findings related to the COVID-19 outbreak.3 This statement committed to open science practices including immediate open access publishing, use of preprints, and data sharing. More than 150 diverse stakeholders globally signed the statement. The consequence has been a greater provision of publicly available information, increased transparency, and rapid access to new COVID-19 information. Even though implementation of these commitments has not been without challenge, likely exacerbated by the rushed nature of their execution, the adoption of actions to open the biomedical research ecosystem in this way, even if incremental rather than truly widespread, is unprecedented. The ability for the research community to share the genetic sequence of the SARS-CoV-2, and the identification of new variants such as omicron, are testaments of the benefit of rapid information sharing for fast-tracking health solutions. In the longer term, we need to ask ourselves what the biomedical community can do to make sustained and widespread changes to ensure that research outputs are rigorous, reproducible, disseminated in a timely fashion, transparent, and publicly accessible. These practices should be central tenants of the research and research dissemination process in all areas of biomedicine and not just temporary actions to address a pandemic. Given the interaction between COVID-19 infection and cardiovascular disease,4,5 some of the cardiology community has been directly impacted by COVID-19 research mandates related to increased openness and transparency. Unfortunately, the community is not broadly prepared to comply with these mandates. Consider data sharing: despite calls over several years to implement data sharing,6,7 and the invaluable insights that could be gained from pooled publicly available datasets, limited data sharing occurs in cardiology. A recent analysis of more than 200 randomly selected articles in cardiology journals found that almost none shared data (96.6%) or analysis scripts (98.7%) openly.8 To reach the goal of open data in cardiology, many challenges need to be addressed, including the creation of data management and sharing policies. Where such policies already exist, they are often not implemented or monitored. As the saying goes, ‘what gets measured, gets done’. One must also consider how to balance open sharing of data with patient consent and privacy, and academic acknowledgement of contributions. Patients have expressed support for data sharing.9 We believe that cardiovascular researchers have not had the tradition, role models, or external requirement to share data. Yet as stewards of patient data, they have an ethical obligation to make data as open as possible to provide access, stimulate discovery, and promote research integrity. We acknowledge that this viewpoint conflicts with the widespread academic reward system that stresses a publish or perish mantra and promotes protectionist thinking about data and intellectual property. Indeed, researchers who aggregate openly available data and publish findings are often labelled as ‘data parasites’ rather than applauded for their distinct methodological influence on innovation and knowledge growth. The time and effort taken to collect individual patient data can be enormous and without proper systems to acknowledge this and to reward researchers for their openness and transparency, behaviour change is unlikely. Finally, there are technical and practical consideration and risks associated with data sharing including the potential for data to be re-identified. Data sharing is unlikely to be successful, even among researchers eager to comply, if standardized training and support are not available. The FAIR Principles10 provide guidance on data management yet we suspect few cardiology researchers are familiar with these. Figure 1 Open in new tabDownload slide Proposed approach to create a cardiovascular research community road map related to open science. Figure 1 Open in new tabDownload slide Proposed approach to create a cardiovascular research community road map related to open science. Data sharing in cardiovascular research is used above to illustrate the potential challenges involved in implementing open science. Developing and adopting a range of open science practices including open code, open access, preprints, study registration, and reporting guideline compliance is necessary to move the research system from its current ‘closed’ standard. Each open science practice will present unique implementation challenges but resource and training requirements, as well as changes to the need to re-evaluate the academic rewards system, are likely to be relevant considerations across all practices. A unified roadmap for how to achieve openness and transparency has not yet been constructed—an effective approach will require breaking down silos among diverse stakeholders in the cardiovascular research community including clinical and preclinical researchers, funders, journal publishers, professional societies, industry, academic institutions, and patients. Here we provide a call to action to start these organized discussions within the cardiovascular research community. Our goal is to clarify which open science practices we ought to prioritize and how to develop a strategic plan and the related training, supports, and resources needed for successful implementation. We envision four steps to move this forward. First, we share this call to action. Then, working with a core leadership team we facilitate a Delphi survey to obtain community feedback. A Delphi is a survey technique that involves controlled iterative surveying of experts to reach consensus on controversial issues. By adopting this standardized survey approach, and through integrated knowledge translation, where knowledge users are engaged from the conception of the work to its translation, we anticipate that the outputs of our efforts will best resonate with the community. Then, we can implement and monitor the plan. The path to implementing openness and transparency in cardiology is unlikely to be a linear one and we recognize that for some open science practices implementation may be incremental rather than disruptive. Cardiovascular research can forge the way within medicine and share lessons learned with the broader biomedical community. If you are interested in joining in on our efforts, please contact us or share your thoughts using the hashtag #OpenUpCardiology. Disclosures K.D.C. is on the Steering Committee of DORA (Declaration On Research Assessment)—this is a volunteer and unpaid role. Conflicts of interest: K.D.C. and P.P.L. declare no conflicts of interest. References 1 Altman DG . The scandal of poor medical research . BMJ 1994 ; 308 : 283 – 284 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Glasziou PP , Sanders S, Hoffmann T. Waste in covid-19 research . BMJ 2020 ; 369 : m1847 . Google Scholar OpenURL Placeholder Text WorldCat 3 Wellcome Trust . Sharing research data and findings relevant to the novel coronavirus (COVID-19) outbreak . https://wellcome.ac.uk/coronavirus-covid-19/open-data (31 January 2020) 4 Bonow RO , O’Gara PT, Yancy CW. Cardiology and COVID-19 . JAMA 2020 ; 324 : 1131 – 1132 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Liu PP , Blet A, Smyth D, Li H. The science underlying COVID-19 . Circulation 2020 ; 142 : 68 – 78 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Ross JS , Krumholz HM. Ushering in a new era of open science through data sharing: the wall must come down . JAMA 2013 ; 309 : 1355 – 1356 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Bauchner H , Golub RM, Fontanarosa PB. Data sharing: an ethical and scientific imperative . JAMA 2016 ; 315 : 1238 – 1240 . Google Scholar Crossref Search ADS WorldCat 8 Anderson JM , Wright B, Rauh S, Tritz D, Horn J, Parker I, et al. Evaluation of indicators supporting reproducibility and transparency within cardiology literature . Heart 2021 ; 107 : 120 – 126 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Mello MM , Lueou V, Goodman SN. Clinical trial participants’ views of the risks and benefits of data sharing . N Engl J Med 2018 ; 378 : 2202 – 2211 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Wilkinson MD , Dumontier M, Aalbersberg IJ, Appleton Ge, Axton M, Baak A, et al. The FAIR guiding principles for scientific data management and stewardship . Sci Data 2016 ; 3 : 160018 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected]

Bhat, Vivek; Ozair, Ahmad; Kumar, Ashish; Kalra, Ankur

doi: 10.1093/eurheartj/ehac140pmid: 35323919

Introduction South Asia, which includes India and neighbouring countries, constitutes nearly a quarter of the world's population, but around 60% of the global cardiovascular disease (CVD) burden.1 With a current prevalence of almost 25 million individuals, India has become a new epicentre of ischemic heart disease (IHD). Its CVD burden, contributing currently to almost 30% of all deaths nationally, has only worsened, given the country's sociodemographic transition, along with the persistently high burden of classical maladies such as rheumatic heart disease.1 Coupled with the rise in IHD has been the increasing prevalence of heart failure (HF), which serves as a noteworthy example.2 India has somewhere between 1.3 and 4.6 million prevalent cases of HF, and an incidence of 0.5 and 1.8 million cases per year.2 IHD is one of the largest risk factors for the development of HF, yet due to infrastructural challenges and inequitable access to quality healthcare, IHD is undertreated for many Indians. Increasing rates of IHD in India will likely contribute to a significant surge of HF in the coming years. This is further compounded by the high prevalence and poor control of diabetes mellitus in India, along with cardiac dysfunction secondary to tobacco use and air pollutants.2 Despite the heavy and increasing burden of CVDs, there is a significant dearth of trained cardiologists in India. Currently, there are only about 4000 cardiologists in the country—1 for every 300 000 Indians.3 Need for advanced sub-specialty training Tackling the rising burden of CVD, while dependent upon the strengthening of primary care, also hinges upon the optimal management of complex cardiac conditions. The latter relies upon access to a large competent workforce of well-trained cardiologists. The standard of care for several CVDs has been continuously evolving, along with expanding complexity of care. Consider, for instance, the management of HF, for which the European Society of Cardiology recently issued updated guidelines.4 With expanding capabilities in HF management, general cardiology training may no longer be sufficient for optimal care, especially for complex patients with multiple co-morbidities. In South Asia, optimum, evidence-based care for HF is received by a poor proportion,2 and early referral to an advanced heart failure and transplant cardiology (AHFTC) could lead to a significant reduction in morbidity indices. In the USA, there exists federal support for advanced HF care, with the Centers for Medicare and Medicaid Services now having expanded access to left ventricular assist devices for HF patients unresponsive to maximum medical care. Such therapies are currently inaccessible to most HF patients in India, but even if available, these patients would still require access to fellowship-trained HF specialists. Similar parallels exist for other major cardiology subspecialties. For instance, wide use of newer imaging modalities such as cardiac magnetic resonance imaging (MRI), expanding procedural skillsets of interventionalists, and the development of complex ablation procedures for arrhythmias—these have all led to growing necessities for sub-specialty cardiology training to ensure delivery of optimal care. Lack of post-cardiology fellowships As of February 2022, India offers 791 accredited positions for cardiology training, 506 accredited by the National Medical Council (NMC) and 285 by the National Board of Examinations (NBEs).5,6 These numbers are comparable with the USA, which offered 1045 positions for ‘CVD’ fellowships at 243 cardiology training programmes in 2021.7 The numbers for sub-specialty training, however, are far lower (Table 1). Table 1 Number of accredited programmes and training spots for the three largest sub-specialty cardiology fellowships in the USA, compared with positions in India Sub-specialty . USA . India . Interventional cardiology 165 programmes ≈334 positions 11 programmes (FNB) 28 positions (FNB) Clinical cardiac electrophysiology 82 programmes 129 positions 1 position (PDF) Advanced heart failure and transplant cardiology 70 programmes 118 positions Zero Sub-specialty . USA . India . Interventional cardiology 165 programmes ≈334 positions 11 programmes (FNB) 28 positions (FNB) Clinical cardiac electrophysiology 82 programmes 129 positions 1 position (PDF) Advanced heart failure and transplant cardiology 70 programmes 118 positions Zero Data are current as of 20 February 2022.5–8 FNB, Fellowship of National Board; PDF, post-doctoral fellowship. Open in new tab Table 1 Number of accredited programmes and training spots for the three largest sub-specialty cardiology fellowships in the USA, compared with positions in India Sub-specialty . USA . India . Interventional cardiology 165 programmes ≈334 positions 11 programmes (FNB) 28 positions (FNB) Clinical cardiac electrophysiology 82 programmes 129 positions 1 position (PDF) Advanced heart failure and transplant cardiology 70 programmes 118 positions Zero Sub-specialty . USA . India . Interventional cardiology 165 programmes ≈334 positions 11 programmes (FNB) 28 positions (FNB) Clinical cardiac electrophysiology 82 programmes 129 positions 1 position (PDF) Advanced heart failure and transplant cardiology 70 programmes 118 positions Zero Data are current as of 20 February 2022.5–8 FNB, Fellowship of National Board; PDF, post-doctoral fellowship. Open in new tab This disparity is further highlighted when one compares the populations of the two countries—India with 1.3 billion individuals, compared with 330 million in the USA (Figure 1). Figure 1 Open in new tabDownload slide Accredited cardiology sub-specialty training spots per 10 million population in India and the USA. The disparity in the number of training spots in interventional cardiology, cardiac electrophysiology, and advanced heart failure and transplant cardiology between the two countries is further highlighted when one accounts for their populations. Figure 1 Open in new tabDownload slide Accredited cardiology sub-specialty training spots per 10 million population in India and the USA. The disparity in the number of training spots in interventional cardiology, cardiac electrophysiology, and advanced heart failure and transplant cardiology between the two countries is further highlighted when one accounts for their populations. Majorly, post-cardiology sub-specialty fellowships in high-income countries exist in (i) interventional cardiology, (ii) cardiac electrophysiology, (iii) AHFTC, (iv) preventive cardiology, (v) advanced cardiac imaging, and (vi) cardio-oncology, among others. Unfortunately, India lacks formal avenues for aspirants to pursue sub-specialty post-cardiology training. Today, most general cardiologists in India who wish to undergo further sub-specialty training join one of the numerous, non-accredited fellowships in teaching institutions and in private hospitals under experienced operators. The vast majority offer training only in interventional cardiology. For other fields, even non-accredited fellowships are unavailable—for example, there is an absolute lack of post-cardiology fellowships in AHFTC. Training spots accredited by NMC or NBEs are few and far between, and are only available in interventional cardiology, cardiac electrophysiology, and paediatric cardiology.5,6 While many of the non-accredited programmes do provide excellent training with a high volume and appropriate case-mix, questions about the uniformity of training are inevitable, given the lack of oversight and accreditation. Therefore, Indians continue to lack access to sub-specialist cardiologists of different kinds, potentially depriving them of the best possible, evidence-based care. Our recommendations are, however, tempered by the fact that many places in India continue to have infrastructural challenges and inequalities in access to cardiovascular care. This must be addressed in parallel alongside training programme expansion. Exploring further directions for sub-specialty cardiovascular training While Indian training programmes still need to create opportunities for our general cardiologists to obtain advanced training, institutions in the USA are moving to expand the available sub-specialty cardiology training. For example, there have been calls to increase the length of interventional cardiology training beyond the existing 1-year fellowship duration,9 with many believing the existing duration to be inadequate, especially given the expanded potential capabilities of today's interventional cardiologists. Additionally, addressing the increasing complexity of care, hybrid training pathways are also being explored. Developing competency-based curricula for advanced fellowship training While planning for the expansion of post-cardiology fellowships, ensuring adequate quality and uniformity of training needs considerable planning and careful execution. Professional bodies must define specific, objective standards, which programmes and trainees must meet for continued accreditation. For example, the current version of the NBE curriculum for Fellowship of National Board—interventional cardiology defines multiple broad goals, in a non-specific manner, without clearly defined milestones for trainees.10 Such vague thresholds deter appropriate oversight and efforts for continuous improvement. In the USA, since 1995, there have been regularly updated Core Cardiology Training Symposium guidelines. These are exemplary in their clarity regarding expectations of trainees at different levels of competence, not just for general cardiology, but also for each sub-specialty. Therefore, not only does Indian cardiology need guidelines for subspecialties, but the existing curricula also need extensive revision. Finally, the curriculum must train cardiology fellows adequately regarding research, given the current concerns regarding the quality and/or utility of research conducted as part of thesis work during general cardiology training in India.3 In addition, an urgent need exists for high-quality outcomes research and health service research (HSR) across India. It is unclear for several cardiac conditions as to how the outcomes vary between states and cities. In many areas, literature is completely lacking regarding access to services—for instance, the nationwide variation in access to advanced cardiac imaging services. With adequate training in and utilization of HSR methods, cardiologists in India can significantly impact public health and policy. Conclusions The evolving complexity and ever-expanding volume of CVDs have necessitated different cardiac sub-specialists. India has an urgent need for strategic and aggressive expansion of accredited sub-specialty cardiology fellowships. These fellowships must prepare graduates to practice at the top of their field and provide a high quality of both clinical and academic training. Funding None. Conflict of interest: none declared. References 1 India State-Level Disease Burden Initiative CVD Collaborators , Prabhakaran D, Jeemon P, Sharma M, Roth GA, Johnson C, et al. The changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990–2016 . Lancet Glob Health 2018 ; 6 : e1339 – e1351 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Martinez-Amezcua P , Haque W, Khera R, Kanaya AM, Sattar N, Lam CSP, et al. The upcoming epidemic of heart failure in South Asia . Circ Heart Fail 2020 ; 13 : e007218 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Talwar KK . Time to revisit super-speciality training programs in cardiology in India . Indian Heart J 2015 ; 67 : 518 – 520 . Google Scholar Crossref Search ADS PubMed WorldCat 4 McDonagh TA , Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure . Eur Heart J 2021 ; 42 : 3599 – 3726 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Department of Accreditation, NBE . NBE Accredited DNB/FNB Seats . Accessed December 30, 2021. https://accr.natboard.edu.in/online_user/frontpage.php. 6 National Medical Commission . College and Course Search . Accessed February 20, 2022. https://www.nmc.org.in/information-desk/college-and-course-search. 7 National Resident Matching Program . National Resident Matching Program, Results and Data: Specialties Matching Service 2021 Appointment Year . Accessed February 20, 2022. https://www.nrmp.org/wp-content/uploads/2021/08/SMS_Result_and_Data_2021.pdf. 8 Fellowship and Residency Electronic Interactive Database . FREIDA Interventional Cardiology (IM) Residency and Fellowship Listing . Accessed February 20, 2022. https://freida.ama-assn.org/specialty/interventional-cardiology-im. 9 Kalra A , Bhatt DL, Pinto DS, Kirtane AJ, Kapadia SR, Makkar RR, et al. Accreditation and funding for a 24-month advanced interventional cardiology fellowship program: a call-to-action for optimal training of the next generation of interventionalists . Catheter Cardiovasc Interv 2016 ; 88 : 1010 – 1015 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Guidelines For Competency Based Training Programme in FNB - Interventional Cardiology . Accessed February 20, 2022. https://nbe.edu.in/mainpdf/curriculum/Final%20Curriculum%20guidelines%20Interventional%20Cardiology.pdf. Published by Oxford University Press on behalf of European Society of Cardiology 2022. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Volpe, Massimo; Galiuto, Leonarda

doi: 10.1093/eurheartj/ehac240pmid: 35514020

Comment on “Childhood Cardiovascular Risk Factors and Adult Cardiovascular Events” which was published in the New England Journal of Medicine, https://doi.org/10.1056/NEJMoa2109191. Key Points This prospective cohort study included participants aged 3–19 years from seven cohorts in Australia, Finland, and the USA enrolled in the International Childhood Cardiovascular Cohorts (i3C) Consortium.1 The study tested the hypothesis that traditional cardiovascular (CV) risk factors (RFs) in childhood are associated with the subsequent development of adult CV events after a mean follow-up of 35 years. Body-mass index (BMI), systolic blood pressure (SBP), total cholesterol level, triglyceride level, and youth smoking were analysed with the use of i3C-derived age- and sex-specific z-scores and with a combined-risk z-score that was calculated as the unweighted mean of the z-scores of the four childhood RFs plus youth smoking as a dichotomous variable. The latter reflected the authors’ hypothesis that all five RFs predict future events, without the estimation of RF weights. An adult combined-risk z-score was analysed in combination with the childhood RFs. Study outcomes were fatal CV events and fatal or non-fatal CV events [first instance of adjudicated myocardial infarction (MI), stroke, transient ischaemic attack, ischaemic heart failure (HF), angina, peripheral artery disease, carotid intervention, abdominal aortic aneurysm, or coronary revascularization]. A total of 38 589 participants (50% male; mean age at childhood visits, 12 ± 3 years) were enrolled. The mean age of the participants at the time of their CV event was 47.0 ± 8.0 years. The risk of fatal CV events in adulthood increased by 30% per unit increase in the z-score for total cholesterol [hazard ratio (HR) 1.30; 95% confidence interval (CI), 1.14–1.47], and by 61% for youth smoking (yes vs. no: HR 1.61; 95% CI, 1.21–2.13). The HR for a fatal CV event in adulthood with respect to the combined-risk z-score was 2.71 (95% CI, 2.23–3.29) per unit increase. Consistent results were achieved in the analyses of non-fatal CV events. There was a higher risk among the participants in the highest category of the RF, and among those in the high-normal or high-acceptable categories for the BMI, SBP, and triglyceride level. Interestingly, RFs during childhood (3–11 years) and adolescence (12–19 years) were similarly related to adult CV events. In the analysis of fatal CV events that occurred in a subgroup of 13 401 participants who had data on adult RFs, the adjusted HR with respect to the childhood combined-risk z-score was 3.54 (95% CI, 2.57–4.87) per unit increase, and the mutually adjusted HR with respect to the change in the combined-risk z-score from childhood to adulthood was 2.88 (95% CI, 2.06–4.05) per unit increase. The results were similar in the analysis of fatal or non-fatal CV events. Participants with CV events were older, more likely to be male, and had a lower parental and personal education level than those without CV events. Comment The importance of CV RFs assessment in childhood and adolescence is still debated. Although CV disease (CVD) typically manifests later in life, a growing body of evidence suggests that CV RFs such as smoking and poor dietary habits often start in childhood.2 The presence of obesity and/or dyslipidaemia in children and adolescents identified through school-based screening programmes has been associated with RFs clustering within families.3 Longitudinal epidemiologic studies have shown that the identification of traditional RFs from childhood to adulthood can improve the prediction of subclinical organ damage in adults.4 Indeed, post-mortem, pathologic, and vessel-wall magnetic resonance imaging analyses of children and adolescents who died in accidents have shown early atherosclerotic lesions consisting of coronary fatty and fibrous plaques particularly in subjects with RFs such as smoking, elevated plasma lipids, obesity, and hypertension.5 The INTERHEART study, involving 52 countries and about 30 000 individuals, demonstrated that smoking, obesity, abnormal lipids, hypertension, diabetes, low consumption of fruits and vegetables, and lack of regular physical activity account for most of the MI risk independent of age, and that RFs are often promoted by shared family lifestyles and poor socioeconomic status.6 In addition, data from the Coronary Artery Risk Development in Young Adults study have shown a relation between the Framingham risk score and CV events among young adults followed for 20 years, though the link between childhood RFs and adult events was not explored.7 In turn, subjects who experienced a lifelong exposure to low levels of low-density lipoprotein cholesterol and systolic blood pressure shared a reduced risk of CV events.8 In such a context, community-based investigations providing longitudinal CV risk data in children may provide an opportunity to investigate the influence of the length of the exposure to RFs in the development of CVD. The analysis of data from the i3C Consortium1 supports the potential role of the presence of traditional RFs in early childhood and adolescence in the development of CV events in young adults, beginning as early as 40 years of age. It should be noted that the childhood combined-risk z-score, when paired with the adult combined-risk z-score, was attenuated and remained independently associated only with fatal or non-fatal CV events. On the other hand, a previous complementary analysis showed that both the childhood combined-risk z-score and the change in combined-risk z-score between childhood and adulthood could predict the risk of CV events across the life course.9 In this regard, further studies may be required to better clarify whether the role of childhood RFs is restricted to their tracking to adult values or may be independently associated with prognosis. Important strengths of the present study1 include the large sample, the adjudication of medical records, and the long follow-up period (mean 35 years). The broad age range can be considered an added value of the study, though it introduces a potential drawback for the role of RFs such as smoking and poor dietary habits, whose distribution can be influenced by age. In such a context, it would have been interesting to stratify the study population in age groups. Other limitations are represented by the predominant inclusion of subjects from relatively high-income countries and White, with a low percentage of Blacks (about 15%) and a minority of Latin and Asian participants. As a consequence, the achieved results might be difficult to translate to other socioeconomic and ethnic subsets. Although further studies may be required, these results have important public health implications and provide strong support for the concept of ‘primordial’ prevention.10 As suggested by the present findings, assessment of CV risk should begin in childhood, and a reduction in RF levels between childhood and adulthood may have the potential to lower the incidence of premature CVD.1 References 1 Jacobs DR Jr, Woo JG, Sinaiko AR, Daniels SR, Ikonen J, Juonala M, et al. Childhood cardiovascular risk factors and adult cardiovascular events . N Engl J Med 2022 . Google Scholar OpenURL Placeholder Text WorldCat 2 Pool LR , Aguayo L, Brzezinski M, Perak AM, Davis MM, Greenland P, et al. Childhood risk factors and adulthood cardiovascular disease: a systematic review . J Pediatr 2021 ; 232 : 118 – 126.e23 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Khoury M , Manlhiot C, Gibson D, Chahal N, Stearne K, Dobbin S, et al. Universal screening for cardiovascular disease risk factors in adolescents to identify high-risk families: a population-based cross-sectional study . BMC Pediatr 2016 ; 16 : 11 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Raitakari O , Pahkala K, Magnussen CG. Prevention of atherosclerosis from childhood . Nat Rev Cardiol 2022 . Google Scholar OpenURL Placeholder Text WorldCat 5 Strong JP , Malcom GT, Newman WP III, Oalmann MC. Early lesions of atherosclerosis in childhood and youth: natural history and risk factors . J Am Coll Nutr 1992 ; 11 : 51S – 54S . Google Scholar Crossref Search ADS PubMed WorldCat 6 Yusuf S , Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case–control study . Lancet 2004 ; 364 : 937 – 952 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Armstrong AC , Jr JD, Gidding SS, Colangelo LA, Gjesdal O, Lewis CE, et al. Framingham score and LV mass predict events in young adults: CARDIA study . Int J Cardiol 2014 ; 172 : 350 – 355 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Ference BA , Bhatt DL, Catapano AL, Packard CJ, Graham I, Kaptoge S, et al. Association of genetic variants related to combined exposure to lower low-density lipoproteins and lower systolic blood pressure with lifetime risk of cardiovascular disease . JAMA 2019 ; 322 : 1381 – 1391 . Google Scholar Crossref Search ADS PubMed WorldCat 9 De Stavola BL , Nitsch D, dos Santos Silva I, McCormack V, Hardy R, Mann V, Cole TJ, Morton S, Leon DA. Statistical issues in life course epidemiology . Am J Epidemiol 2006 ; 163 : 84 – 96 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Climie R , Fuster V, Empana JP. Health literacy and primordial prevention in childhood-an opportunity to reduce the burden of cardiovascular disease . JAMA Cardiol 2020 ; 5 : 1323 – 1324 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology. All rights reserved. For permissions, please e-mail: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Batra, Gorav; Aktaa, Suleman; Wallentin, Lars; Maggioni, Aldo P; Ludman, Peter; Erlinge, David; Casadei, Barbara; Gale, Chris P; ,

doi: 10.1093/eurheartj/ehac133pmid: 35380662

Graphical AbstractGraphical AbstractDomains of the 2021 EuroHeart acute coronary syndrome and percutaneous coronary intervention data standards with the number of Level 1 (mandatory) variables.

doi: 10.1093/eurheartj/ehac187pmid: 35393621

European Heart Journal, https://doi.org/10.1093/eurheartj/ehac116. In the originally published version of this manuscript, the graphical abstract had two errors, as follows: (1) The legend incorrectly labeled Group 5 as “persistent nonadherence”; the correct label for this group is “persistent adherence”. (2) the rightmost graphical abstract figure was a duplicate of the middle figure; it has been replaced with the correct figure, a Kaplan-Meier plot of major adverse cardiovascular events by P2Y12 inhibitor adherence trajectory group, stratified by stent type. These errors have been corrected. © The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology. All rights reserved. For permissions, please e-mail: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Nevraumont, Arnaud; Deltombe, Matthieu; Favresse, Julien; Guillaume, Louise; Chapelle, Virginie; Twerenbold, Raphael; Gruson, Damien

doi: 10.1093/eurheartj/ehab924pmid: 35084447

Graphical AbstractGraphical AbstractClinical impact of interferences with cardiac biomarker assays from 222 case reports published between January 1996 and July 2021. ECG, electrocardiography; CTA, computed tomography angiography; PCI, percutaneous coronary intervention; MRI, magnetic resonance imaging.

Moledina, Saadiq M; Kontopantelis, Evangelos; Wijeysundera, Harindra C; Banerjee, Shrilla; Van Spall, Harriette G C; Gale, Chris P; Shah, Benoy N; Mohamed, Mohamed O; Weston, Clive; Shoaib, Ahmad; Mamas, Mamas A

Schiele, François; Meneveau, Nicolas

doi: 10.1093/eurheartj/ehac027pmid: 35254420

Graphical AbstractGraphical AbstractBurden of published and validated scores potentially useful in NSTEMI patients for risk stratification (left column) and for decision-making (right column). References of the publications can be found by simple internet search using (i) prediction AND ACS and (ii) the headline of the box or line; or title of the indication and (iii) the name of the score.