Medical Bulletin 27/ September/ 2024 - Video

Women across the globe, are still missing out on vital treatment for their No 1 killer—cardiovascular disease—despite significant progress in the medical management of heart disease and stroke, concludes a consensus statement published online in the journal Heart.

Conventional cardiovascular disease risk factors, such as high blood pressure and high cholesterol, are often not treated as promptly or as appropriately as they are in men, despite accounting for around half of all preventable cardiovascular disease deaths, says the statement.

Healthcare professionals and the public mistakenly believe that women’s risk of cardiovascular disease is lower than men’s, says the statement. “Myths and unconscious biases within clinical practices and societal perceptions further obscure the reality that heart disease does not discriminate by sex,” it says.

And all too often women’s voices are unheard and their heart symptoms aren’t taken seriously enough, it adds.

The statement sets out a series of actions for clinicians and their professional bodies in each of the major cardiovascular disease areas.

These include:

• Raising awareness of traditional and women-specific risk factors for all types of cardiovascular disease

• Ensuring that women are included in cardiovascular disease research

• Making sure that the public and clinicians know that coronary artery disease is the leading cause of death for women

• Ensuring equitable access to specialist cardiac care, genetic testing, and family screening for women with inherited heart disease

• Addressing the under-representation of women in clinical trials of new cancer immunotherapy treatments

• Setting up registries to monitor cardiac toxicity as a result of cancer chemotherapy for everyone, and specifically for women

• Enhancing women’s participation in cardiac rehabilitation programmes by offering flexible hybrid/virtual options

• Increasing clinician awareness of the strengths and limitations of each diagnostic method in women with confirmed or suspected cardiovascular disease

• Making women’s cardiovascular disease health ‘everyone’s responsibility’ by including this in primary care clinicians’ contractual obligations

• Leveraging influence to highlight and address sex biases in healthcare

Patients and those advocating on their behalf also have a role in advancing women’s cardiovascular disease care, says the statement.

For example, they should:

• Call for a holistic woman-centred approach to heart care that incorporates women’s experiences and insights

• They should engage the media, among others, to raise awareness about the importance of cardiovascular health for women.

• Tailor information to the unique needs of women

• Highlight heart conditions that predominantly or exclusively affect women

• Co-design training for healthcare professionals to become more attuned to women’s specific needs

The statement also calls for the establishment of women’s heart champions to offer peer to peer support and dedicated women’s heart hubs to check on conventional risk factors, such as blood pressure, cholesterol, and weight, and provide lifestyle advice on diet and exercise. And a dedicated women’s health strategy should be created, it suggests.

Reference: Tayal U, Pompei G, Wilkinson I, et al Advancing the access to cardiovascular diagnosis and treatment among women with cardiovascular disease: a joint British Cardiovascular Societies’ consensus document Heart Published Online First: 24 September 2024. doi: 10.1136/heartjnl-2024-324625

New research conducted at Columbia Mailman School of Public Health and Mount Sinai School of Medicine shows a link between prediabetes among young people and adverse pregnancy outcomes later in life. The findings could alter how doctors routinely screen or counsel youth on blood glucose levels, and subsequently, minimize potential maternal and neonatal risks. The results are published in JAMA Network Open.

“This study is an important step in tying lifecourse cardiometabolic health to optimal pregnancy outcomes,” said Teresa Janevic, PhD, associate professor of Epidemiology at Columbia University Mailman School of Public Health and senior author. “The findings point to an opportunity to invest in adolescent health to promote later healthy pregnancies.”

In their new study, the researchers examined the significance of prediabetes prior to conception among adolescents and young adults, a group that is most at risk of unplanned pregnancy and least likely to benefit from preconception health counseling.

The study of more than 14,000 people between ages 10 and 24 years was generated by linking New York City birth registry, hospital discharge, and A1C Registry data between 2009 and 2017 and included individuals who had no history of diabetes and at least one hemoglobin A1c (HbA1c) test prior to first birth. The researchers found that preconception prediabetes was associated with more than twice the likelihood of gestational diabetes at future first birth. The experts discovered that prediabetes during youth and adolescence could result in an 18 percent increased risk of hypertensive disorders during pregnancy, such as gestational hypertension and preeclampsia, or preterm delivery.

The study also assessed what level of hemoglobin A1c, a measure of a person’s average blood sugar level over the prior three months, was most predictive of gestational diabetes at first birth among adolescents and young adults. The optimal threshold was slightly lower for young people than that used for adults. Overall, the study results support the need to establish clear clinical guidance on how to screen and counsel young people who currently have elevated blood glucose levels without other risk factors, the researchers said.

“The lack of uniform preconception prediabetes treatment guidelines for adolescents may represent a missed opportunity to avert pregnancy-related complications,” said corresponding author Katharine McCarthy, PhD, assistant professor of Population Health Science and Policy, and Obstetrics, Gynecology and Reproductive Science at the Icahn School of Medicine at Mount Sinai.

“Our results support expanded preconception hemoglobin A1c screening as a mechanism to intervene on excess cardiometabolic risk earlier in the life course,” noted the researchers.

Reference: McCarthy KJ, Liu SH, Kennedy J, et al. Preconception HbA 1c Levels in Adolescents and Young Adults and Adverse Birth Outcomes. JAMA Netw Open. 2024;7(9):e2435136. doi:10.1001/jamanetworkopen.2024.35136

In a review of previous studies, a Johns Hopkins Children’s Center team concludes that some video games created as mental health interventions can be helpful – if modest – tools in improving the mental well-being of children and teens with anxiety, depression and attention-deficit/hyperactivity disorder (ADHD).

A report on the review of studies from peer-reviewed journals between 2011 and March 20, 2024, was published in JAMA Pediatrics.

“We found literature that suggests that even doubling the number of pediatric mental health providers still wouldn’t meet the need,” says Barry Bryant, M.D., a resident in the Department of Psychiatry and Behavioral Sciences in the Johns Hopkins University School of Medicine and first author of the new study.

In a bid to determine if so-called “gamified digital mental health interventions,” or video games designed to treat mental health conditions, benefited those with anxiety, depression and ADHD, the research team analyzed their use in randomized clinical trials for children and adolescents.

Bryant and child and adolescent psychologist Joseph McGuire, Ph.D., identified 27 such trials from the U.S. and around the world. The studies overall included 2,911 participants with about half being boys and half being girls, between the ages of six and 17 years old.

The digital mental health interventions varied in content, but were all created with the intent of treating ADHD, depression and anxiety. All games were conducted on technology platforms, such as computers, tablets, video game consoles and smartphones. The video games are available to users in a variety of ways — some are available online, while others required access through specific research teams involved in the studies.

Outcome measurements varied depending on the study. However, the Johns Hopkins research team was able to standardize effect sizes using a random-effects model so that a positive result indicated when interventions performed better than control conditions. Hedges g, a statistic used to measure effect size, was used to quantify treatment effects overall in the studies reviewed.

The research team’s analysis found that video games designed for patients with ADHD and depression provided a modest reduction in symptoms related to ADHD and depression, such as improved ability to sustain attention and decreased sadness, based on participant and family feedback from the studies. By contrast, video games designed for anxiety did not show meaningful benefits for reducing anxiety symptoms for participants, based on participant and family feedback.

Researchers also examined factors that led to improved benefit from digital mental health interventions. Specific factors related to video game delivery and participants (i.e., studies that involved more boys) were found to positively influence therapeutic effects.

“While the benefits are still modest, our research shows that we have some novel tools to help improve children’s mental health — particularly for ADHD and depression — that can be relatively accessible to families,” says Joseph McGuire, Ph.D., an author of the study and an associate professor of psychiatry and behavioral sciences in the school of medicine. “So if you are a pediatrician and you’re having trouble getting your pediatric patient into individual mental health care, there could be some gamified mental health interventions that could be nice first steps for children while waiting to start individual therapy.”

Reference: Bryant BR, Sisk MR, McGuire JF. Efficacy of Gamified Digital Mental Health Interventions for Pediatric Mental Health Conditions: A Systematic Review and Meta- Analysis. JAMA Pediatr. Published online September 23, 2024.

doi:10.1001/jamapediatrics.2024.3139

The 2024 guideline for cardiovascular management of adults undergoing noncardiac surgery reflects a decade of updates and new evidence since the guideline’s last release in 2014. It is published in the American Heart Association’s flagship, peer-reviewed journal Circulation and simultaneously in JACC, the flagship journal of the American College of Cardiology.

The recommendations address patient evaluations and assessments, use of cardiovascular testing and screening, and evidence-based management of cardiovascular conditions and risks before, during and after surgery in those patients.

“There is a wealth of new evidence about how best to evaluate and manage perioperative cardiovascular risk in patients undergoing noncardiac surgery,” said Chair of the guideline writing group Annemarie Thompson, M.D., M.B.A., FAHA, a professor of anesthesiology, medicine and population health sciences at Duke University Medical Center in Durham, North Carolina.

“From prior studies, conditions such as high blood pressure, Type 2 diabetes, age older than 55 in men and 65 in women, smoking and obesity are known risk factors that predispose patients to cardiovascular disease. Others have a family history of premature coronary artery disease, which can also put them at increased risk,” Thompson said. “This guideline is written with the understanding that these and other cardiovascular risk factors and conditions can contribute to negative surgical outcomes if they are unrecognized or not optimized before surgery.”

Perioperative Management of Cardiovascular Conditions

As in 2014, the 2024 guideline includes a perioperative algorithm to guide health care professionals in care decisions for patients with cardiovascular conditions having noncardiac surgery. The new guideline reviews blood pressure management before, during and after surgery, and highlights specific recommendations for patients with coronary artery disease, hypertrophic cardiomyopathy, valvular heart disease, pulmonary hypertension, obstructive sleep apnea and previous stroke.

Updated Screening Recommendations

The new guideline recommends that health care professionals be judicious and targeted about ordering screenings, such as stress testing, to determine cardiac risk prior to surgery.

The guideline also includes recommendations on using emergency-focused cardiac ultrasound for patients undergoing noncardiac surgery with unexplained hemodynamic instability if clinicians with expertise in cardiac ultrasound are readily available.

Considerations for Medication Management

Newer medications for Type 2 diabetes, heart failure and obesity management have important perioperative implications, according to the 2024 guideline. SGLT2-inhibitors should be discontinued three to four days before surgery to minimize the risk of perioperative ketoacidosis, which is unbalanced pH levels in the blood that can negatively impact surgical outcomes.

Emerging data suggest that glucagon-like polypeptide-1 (GLP-1) agonists, medications that are used for managing type 2 diabetes and/or obesity, may cause delayed stomach emptying. In addition, nausea is a common side effect of GLP-1 agonists, and patients taking these medications may be at increased risk of pulmonary aspiration, or inhaling stomach content into their lungs, while under anesthesia.

For patients who are taking blood thinners, the new guideline recommends that in most cases it is safe to stop blood thinners several days before surgery, proceed to surgery and then start taking blood thinners again after surgery, most commonly after hospital discharge.

Additional Research Needs Identified

Myocardial injury after noncardiac surgery (MINS), or injury to the heart that occurs either during or shortly after noncardiac surgery, is diagnosed by elevated cardiac troponin levels after surgery. In patients who develop MINS, outpatient follow-up is recommended to counsel patients on how to reduce their heart disease risk factors.

Patients with newly diagnosed AFib have an increased risk of stroke, and guideline authors recommend closely following these patients after surgery to treat reversible causes of AFib and to consider the need for rhythm control and/or the use of blood thinners to prevent stroke.

Reference: Thompson, A., Fleischmann, K. E., Smilowitz, N. R., de las Fuentes, L., Mukherjee, D., Aggarwal, N. R., Ahmad, F. S., Allen, R. B., Altin, S. E., Auerbach, A., Berger, J. S., Chow, B., Dakik, H. A., Eisenstein, E. L., Gerhard-Herman, M., Ghadimi, K., Kachulis, B., Leclerc, J., Lee, C. S., Macaulay, T. E., Mates, G., Merli, G. J., Parwani, P., Poole, J. E., Rich, M. W., Ruetzler, K., Stain, S. C., Sweitzer, B., Talbot, A. W., Vallabhajosyula, S., Whittle, J., & Williams, K. A. (2024). 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. https://doi.org/10.1161/CIR.0000000000001285