Publications by authors named "Karen Sliwa"

306 Publications

Peripartum cardiomyopathy: from genetics to management.

Eur Heart J 2021 Jul 28. Epub 2021 Jul 28.

Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.

Peripartum cardiomyopathy (PPCM) is a disease that occurs globally in all ethnic groups and should be suspected in any peripartum women presenting with symptoms and signs of heart failure, towards the end of pregnancy or in the months following delivery, with confirmed left ventricular dysfunction. After good history taking, all women should be thoroughly assessed, and alternative causes should be excluded. Urgent cardiac investigations with electrocardiogram and natriuretic peptide measurement (if available) should be performed. Echocardiography follows as the next step in investigation. Patients with abnormal cardiac investigations should be urgently referred to a cardiology team for expert management. Referral for genetic work-up should be considered if there is a family history of cardiomyopathy or sudden death. PPCM is a disease with substantial maternal and neonatal morbidity and mortality. Maternal mortality rates range widely, from 0% to 30%, depending on the ethnic background and geographic region. Just under half of women experience myocardial recovery. Remarkable advances in the comprehension of the pathogenesis and in patient management and therapy have been achieved, largely due to team efforts and close collaboration between basic scientists, cardiologists, intensive care specialists, and obstetricians. This review summarizes current knowledge of PPCM genetics, pathophysiology, diagnostic approach, management, and outcome.
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http://dx.doi.org/10.1093/eurheartj/ehab458DOI Listing
July 2021

Moving Ahead: Building a Strong Network Among Female Cardiovascular Clinician Scientists and Researchers in Africa.

JACC Case Rep 2019 Jun 19;1(1):40-43. Epub 2019 Jun 19.

Instituto Nacional de Saúde and Eduardo Mondlane University, Maputo, Mozambique.

This case reports on the authors' successes building a strong network among female cardiovascular clinician scientists and researchers in Africa provides examples of collaborations and mentorship. ().
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http://dx.doi.org/10.1016/j.jaccas.2019.05.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8288572PMC
June 2019

[Aortic and valvular heart diseases, cardiomyopathies and heart failure in pregnancy : Risk assessment and management].

Herz 2021 Jul 14. Epub 2021 Jul 14.

Cape Heart Institute, Faculty of Health Sciences, University of Cape Town, Cape Town, Südafrika.

Women with known cardiovascular diseases (CVD) and a desire to have children should receive a timely comprehensive counselling before becoming pregnant. This is critical as the foundation for an informed decision-making process of the mother and her family. Furthermore, a detailed interdisciplinary management plan should be developed and discussed with the patient. The modified World Health Organization (mWHO) classification should be applied for maternal cardiovascular risk stratification. Although the prevalence of aortic pathologies is infrequent, they are often life-threatening conditions. Following the recent advances in terms of surgical management and anticoagulation, the adequate management of valvular heart disease is particularly challenging. Cardiomyopathies during pregnancy are associated with high maternal mortality and severe cardiovascular complications, such as progressive heart failure and thromboembolic events; however, novel treatment options have recently become available.
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http://dx.doi.org/10.1007/s00059-021-05049-8DOI Listing
July 2021

Heat Shock Proteins: Potential Modulators and Candidate Biomarkers of Peripartum Cardiomyopathy.

Front Cardiovasc Med 2021 16;8:633013. Epub 2021 Jun 16.

Department of Medicine, Faculty of Health Sciences, Cape Heart Institute, University of Cape Town, Cape Town, South Africa.

Peripartum cardiomyopathy (PPCM) is a potentially life-threatening condition in which heart failure and systolic dysfunction occur late in pregnancy or within months following delivery. To date, no reliable biomarkers or therapeutic interventions for the condition exist, thus necessitating an urgent need for identification of novel PPCM drug targets and candidate biomarkers. Leads for novel treatments and biomarkers are therefore being investigated worldwide. Pregnancy is generally accompanied by dramatic hemodynamic changes, including a reduced afterload and a 50% increase in cardiac output. These increased cardiac stresses during pregnancy potentially impair protein folding processes within the cardiac tissue. The accumulation of misfolded proteins results in increased toxicity and cardiac insults that trigger heart failure. Under stress conditions, molecular chaperones such as heat shock proteins (Hsps) play crucial roles in maintaining cellular proteostasis. Here, we critically assess the potential role of Hsps in PPCM. We further predict specific associations between the Hsp types Hsp70, Hsp90 and small Hsps with several proteins implicated in PPCM pathophysiology. Furthermore, we explore the possibility of select Hsps as novel candidate PPCM biomarkers and drug targets. A better understanding of how these Hsps modulate PPCM pathogenesis holds promise in improving treatment, prognosis and management of the condition, and possibly other forms of acute heart failure.
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http://dx.doi.org/10.3389/fcvm.2021.633013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241919PMC
June 2021

Transition to adulthood and transfer to adult care of adolescents with congenital heart disease: a global consensus statement of the ESC Association of Cardiovascular Nursing and Allied Professions (ACNAP), the ESC Working Group on Adult Congenital Heart Disease (WG ACHD), the Association for European Paediatric and Congenital Cardiology (AEPC), the Pan-African Society of Cardiology (PASCAR), the Asia-Pacific Pediatric Cardiac Society (APPCS), the Inter-American Society of Cardiology (IASC), the Cardiac Society of Australia and New Zealand (CSANZ), the International Society for Adult Congenital Heart Disease (ISACHD), the World Heart Federation (WHF), the European Congenital Heart Disease Organisation (ECHDO), and the Global Alliance for Rheumatic and Congenital Hearts (Global ARCH).

Eur Heart J 2021 Jul 1. Epub 2021 Jul 1.

KU Leuven Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 35, Box 7001, B-3000 Leuven, Belgium.

The vast majority of children with congenital heart disease (CHD) in high-income countries survive into adulthood. Further, paediatric cardiac services have expanded in middle-income countries. Both evolutions have resulted in an increasing number of CHD survivors. Expert care across the life span is necessitated. In adolescence, patients transition from being a dependent child to an independent adult. They are also advised to transfer from paediatrics to adult care. There is no universal consensus regarding how transitional care should be provided and how the transfer should be organized. This is even more challenging in countries with low resources. This consensus document describes issues and practices of transition and transfer of adolescents with CHD, accounting for different possibilities in high-, middle-, and low-income countries. Transitional care ought to be provided to all adolescents with CHD, taking into consideration the available resources. When reaching adulthood, patients ought to be transferred to adult care facilities/providers capable of managing their needs, and systems have to be in place to make sure that continuity of high-quality care is ensured after leaving paediatric cardiology.
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http://dx.doi.org/10.1093/eurheartj/ehab388DOI Listing
July 2021

Cardiovascular outcomes in patients at high cardiovascular risk with previous myocardial infarction or stroke.

J Hypertens 2021 Aug;39(8):1602-1610

Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg.

Background: Guidelines recommend to start blood pressure (BP)-lowering drugs also according to cardiovascular risk including history of cardiovascular events. We hypothesized that in patients with a history of myocardial infarction (MI), stroke, both or none of those, the index events predict the next event and have different SBP risk associations to different cardiovascular outcomes.

Design And Measurements: In this pooled posthoc, nonprespecified analysis, we assessed outcome data from high-risk patients aged 55 years or older with a history of cardiovascular events or proven cardiovascular disease, randomized to the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial and to Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease Trial investigating telmisartan, ramipril and their combination with a median follow-up of 56 months. Standardized office BP was measured every 6 months. Associations of mean achieved BP on treatment were investigated on MI, stroke and cardiovascular death. We identified patients with previous MI (N = 13 487), stroke (N = 4985), both (N = 1509) or none (N = 10 956) of these index events. Analyses were done by Cox regression, analysis of variance and Chi2-test. 30 937 patients with complete data were enrolled between 1 December 2001 and 31 July 2003, and followed until 31 July 2008. Data of both trials were pooled as the outcomes were similar.

Results: Patients with MI as index event had a higher risk to experience a second MI [hazard ratio 1.42 (confidence interval (CI) 1.20-1.69), P < 0.0001] compared with patients with no events but no increased risk for a stroke as a next event [hazard ratio 0.95 (CI 0.73-1.23), n.s.]. The risk was roughly doubled when they had both, MI and stroke before [hazard ratio 2.07 (CI 1.58-2.71), P < 0.0001]. Patients with a stroke history had a roughly three-fold higher likelihood to experience a second stroke [hazard ratio 2.89 (CI 2.37-3.53) P < 0.0001] but not MI [hazard ratio 1.07 (CI 0.88-1.32), n.s.]. Both types of index events increased roughly three-fold the risk of a second stroke compared with no previous events. The SBP-risk relationship was not meaningfully altered by the event history. After MI and stroke the risk for subsequent events and cardiovascular death was increased over the whole SBP spectrum. A J-shape relationship between BP and outcome was only observed for cardiovascular death.

Conclusion: Previous MI and previous stroke are associated with increased risk for the same event in the future, independent of achieved SBP. Thus, secondary prevention may also be chosen according to the event history of patients.

Clinical Trial Registration: http://clinicaltrials.gov. Unique identifier: NCT00153101.
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http://dx.doi.org/10.1097/HJH.0000000000002822DOI Listing
August 2021

Disparities in clinical features and outcomes of peripartum cardiomyopathy in high versus low prevalent regions in Nigeria.

ESC Heart Fail 2021 Jun 17. Epub 2021 Jun 17.

Hatter Institute for Cardiovascular Research in Africa & CHI, Cape Town, South Africa.

Aims: The prospective, multicentre Peripartum Cardiomyopathy in Nigeria (PEACE) registry originally demonstrated a high prevalence of peripartum cardiomyopathy (PPCM) among patients originating from Kano, North-West Nigeria. In a post hoc analysis, we sought to determine if this phenomenon was characterized by a differential case profile and outcome among PPCM cases originating elsewhere.

Methods And Results: Overall, 199 (81.6%) of a total 244 PPCM patients were recruited from three sites in Kano, compared with 45 patients (18.4%) from 11 widely dispersed centres across Nigeria. Presence and extent of ventricular myocardial remodelling during follow-up, relative to baseline status, were assessed by echocardiography. During median 17 months follow-up, Kano patients demonstrated significantly better myocardial reverse remodelling than patients from other sites. Overall, 50.6% of patients from Kano versus 28.6% from other regions were asymptomatic (P = 0.029) at study completion, with an accompanying difference in all-cause mortality (17.6% vs. 22.2% respectively, P = 0.523) not reaching statistical significance. Alternatively, 135/191 (84.9%) of Kano patients had selenium deficiency (<70 μg/L), and 46/135 (34.1%) of them received oral selenium supplementation. Critically, those that received selenium supplementation demonstrated better survival (6.5% vs. 21.2%; P = 0.025), but the supplement did not have significant impact on myocardial remodelling.

Conclusions: This study has shown important non-racial regional disparities in the clinical features and outcomes of PPCM patients in Nigeria, that might partly be explained by selenium supplementation.
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http://dx.doi.org/10.1002/ehf2.13463DOI Listing
June 2021

Hypertensive disorders in women with peripartum cardiomyopathy: insights from the ESC Peripartum Cardiomyopathy Registry.

Eur J Heart Fail 2021 Jun 11. Epub 2021 Jun 11.

Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands.

Aims: Hypertensive disorders occur in women with peripartum cardiomyopathy (PPCM). How often hypertensive disorders co-exist, and to what extent they impact outcomes, is less clear. We describe differences in phenotype and outcomes in women with PPCM with and without hypertensive disorders during pregnancy.

Methods: The European Society of Cardiology PPCM Registry enrolled women with PPCM from 2012-2018. Three groups were examined: 1) women without hypertension ('PPCM-noHTN'); 2) women with hypertension but without pre-eclampsia ('PPCM-HTN'); 3) women with pre-eclampsia ('PPCM-PE'). Maternal (6-month) and neonatal outcomes were compared.

Results: Of 735 women included, 452 (61.5%) had PPCM-noHTN, 99 (13.5%) had PPCM-HTN and 184 (25.0%) had PPCM-PE. Compared to women with PPCM-noHTN, women with PPCM-PE had more severe symptoms (NYHA IV in 44.4% and 29.9%, p<0.001), more frequent signs of heart failure (pulmonary rales in 70.7% and 55.4%, p=0.002), higher baseline LVEF (32.7% and 30.7%, p=0.005) and smaller left ventricular end diastolic diameter (57.4mm [±6.7] and 59.8mm [±8.1], p<0.001). There were no differences in the frequencies of death from any cause, re-hospitalization for any cause, stroke, or thromboembolic events. Compared to women with PPCM-noHTN, women with PPCM-PE had a greater likelihood of left ventricular recovery (LVEF≥50%) (adjusted OR 2.08 95% CI 1.21-3.57) and an adverse neonatal outcome (composite of termination, miscarriage, low birth weight or neonatal death) (adjusted OR 2.84 95% CI 1.66-4.87).

Conclusion: Differences exist in phenotype, recovery of cardiac function and neonatal outcomes according to hypertensive status in women with PPCM.
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http://dx.doi.org/10.1002/ejhf.2264DOI Listing
June 2021

Climate Action for Health: An Urgent Call from the Global Cardiovascular Community.

Glob Heart 2021 May 3;16(1):33. Epub 2021 May 3.

University of Cape Town, ZA.

The current and immediate past Presidents of the World Heart Federation are pleased to publish this invited editorial to demonstrate the organization's strong, ongoing commitment to addressing the impacts of air pollution on cardiovascular health and outline its strategy for action.
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http://dx.doi.org/10.5334/gh.1051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103849PMC
May 2021

The World Heart Federation Global Study on COVID-19 and Cardiovascular Disease.

Glob Heart 2021 04 19;16(1):22. Epub 2021 Apr 19.

Centre for Control of Chronic Conditions, Public Health Foundation India, World Heart Federation, London School of Hygiene & Tropical Medicine, UK.

Background: The emergence of novel coronavirus disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), has presented an unprecedented global challenge for the healthcare community. The ability of SARS-CoV-2 to get transmitted during the asymptomatic phase, and its high infectivity have led to the rapid transmission of COVID-19 beyond geographic regions facilitated by international travel, leading to a pandemic. To guide effective control and interventions, primary data is required urgently, globally, including from low- and middle-income countries where documentation of cardiovascular manifestations and risk factors in people hospitalized with COVID-19 is limited.

Objectives: This study aims to describe the cardiovascular manifestations and cardiovascular risk factors in patients hospitalized with COVID-19.

Methods: We propose to conduct an observational cohort study involving 5000 patients recruited from hospitals in low-, middle- and high-income countries. Eligible adult COVID-19 patients will be recruited from the participating hospitals and followed-up until 30 days post admission. The outcomes will be reported at discharge and includes the need of ICU admission, need of ventilator, death (with cause), major adverse cardiovascular events, neurological outcomes, acute renal failure, and pulmonary outcomes.

Conclusion: Given the enormous burden posed by COVID-19 and the associated severe prognostic implication of CVD involvement, this study will provide useful insights on the risk factors for severe disease, clinical presentation, and outcomes of various cardiovascular manifestations in COVID-19 patients particularly from low and middle income countries from where the data remain scant.
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http://dx.doi.org/10.5334/gh.950DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8064295PMC
April 2021

Time for cardiac care in pregnancy: beyond 42 days post-partum.

Glob Cardiol Sci Pract 2021 Apr 30;2021(1):e202106. Epub 2021 Apr 30.

Instituto Nacional de Saúde, Marracuene, Moçambique.

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http://dx.doi.org/10.21542/gcsp.2021.6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8133783PMC
April 2021

An investment case for the prevention and management of rheumatic heart disease in the African Union 2021-30: a modelling study.

Lancet Glob Health 2021 Jul 10;9(7):e957-e966. Epub 2021 May 10.

Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA; Program in Global Noncommunicable Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Partners In Health, Boston, MA, USA. Electronic address:

Background: Despite declines in deaths from rheumatic heart disease (RHD) in Africa over the past 30 years, it remains a major cause of cardiovascular morbidity and mortality on the continent. We present an investment case for interventions to prevent and manage RHD in the African Union (AU).

Methods: We created a cohort state-transition model to estimate key outcomes in the disease process, including cases of pharyngitis from group A streptococcus, episodes of acute rheumatic fever (ARF), cases of RHD, heart failure, and deaths. With this model, we estimated the impact of scaling up interventions using estimates of effect sizes from published studies. We estimated the cost to scale up coverage of interventions and summarised the benefits by monetising health gains estimated in the model using a full income approach. Costs and benefits were compared using the benefit-cost ratio and the net benefits with discounted costs and benefits.

Findings: Operationally achievable levels of scale-up of interventions along the disease spectrum, including primary prevention, secondary prevention, platforms for management of heart failure, and heart valve surgery could avert 74 000 (UI 50 000-104 000) deaths from RHD and ARF from 2021 to 2030 in the AU, reaching a 30·7% (21·6-39·0) reduction in the age-standardised death rate from RHD in 2030, compared with no increase in coverage of interventions. The estimated benefit-cost ratio for plausible scale-up of secondary prevention and secondary and tertiary care interventions was 4·7 (2·9-6·3) with a net benefit of $2·8 billion (1·6-3·9; 2019 US$) through 2030. The estimated benefit-cost ratio for primary prevention scale-up was low to 2030 (0·2, <0·1-0·4), increasing with delayed benefits accrued to 2090. The benefit-cost dynamics of primary prevention were sensitive to the costs of different delivery approaches, uncertain epidemiological parameters regarding group A streptococcal pharyngitis and ARF, assumptions about long-term demographic and economic trends, and discounting.

Interpretation: Increased coverage of interventions to control and manage RHD could accelerate progress towards eradication in AU member states. Gaps in local epidemiological data and particular components of the disease process create uncertainty around the level of benefits. In the short term, costs of secondary prevention and secondary and tertiary care for RHD are lower than for primary prevention, and benefits accrue earlier.

Funding: World Heart Federation, Leona M and Harry B Helmsley Charitable Trust, and American Heart Association.
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http://dx.doi.org/10.1016/S2214-109X(21)00199-6DOI Listing
July 2021

Lowering cholesterol, blood pressure, or both to prevent cardiovascular events: results of 8.7 years of follow-up of Heart Outcomes Evaluation Prevention (HOPE)-3 study participants.

Eur Heart J 2021 May 8. Epub 2021 May 8.

The Population Health Research Institute, Hamilton Health Sciences, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.

Aims: Rosuvastatin (10 mg per day) compared with placebo reduced major adverse cardiovascular (CV) events by 24% in 12 705 participants at intermediate CV risk after 5.6 years. There was no benefit of blood pressure (BP) lowering treatment in the overall group, but a reduction in events in the third of participants with elevated systolic BP. After cessation of all the trial medications, we examined whether the benefits observed during the active treatment phase were sustained, enhanced, or attenuated.

Methods And Results: After the randomized treatment period (5.6 years), participants were invited to participate in 3.1 further years of observation (total 8.7 years). The first co-primary outcome for the entire length of follow-up was the composite of myocardial infarction, stroke, or CV death [major adverse cardiovascular event (MACE)-1], and the second was MACE-1 plus resuscitated cardiac arrest, heart failure, or coronary revascularization (MACE-2). In total, 9326 (78%) of 11 994 surviving Heart Outcomes Prevention Evaluation (HOPE)-3 subjects consented to participate in extended follow-up. During 3.1 years of post-trial observation (total follow-up of 8.7 years), participants originally randomized to rosuvastatin compared with placebo had a 20% additional reduction in MACE-1 [95% confidence interval (CI), 0.64-0.99] and a 17% additional reduction in MACE-2 (95% CI 0.68-1.01). Therefore, over the 8.7 years of follow-up, there was a 21% reduction in MACE-1 (95% CI 0.69-0.90, P = 0.005) and 21% reduction in MACE-2 (95% CI 0.69-0.89, P = 0.002). There was no benefit of BP lowering in the overall study either during the active or post-trial observation period, however, a 24% reduction in MACE-1 was observed over 8.7 years.

Conclusion: The CV benefits of rosuvastatin, and BP lowering in those with elevated systolic BP, compared with placebo continue to accrue for at least 3 years after cessation of randomized treatment in individuals without cardiovascular disease indicating a legacy effect.

Trial Registration Number: NCT00468923.
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http://dx.doi.org/10.1093/eurheartj/ehab225DOI Listing
May 2021

Health-Related Quality of Life and Mortality in Heart Failure: The Global Congestive Heart Failure Study of 23 000 Patients From 40 Countries.

Circulation 2021 Jun 28;143(22):2129-2142. Epub 2021 Apr 28.

Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada (I.J., P.J., K.B., B.F., K.T., A.G., T.M., S.Y.).

Background: Poor health-related quality of life (HRQL) is common in heart failure (HF), but there are few data on HRQL in HF and the association between HRQL and mortality outside Western countries.

Methods: We used the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) to record HRQL in 23 291 patients with HF from 40 countries in 8 different world regions in the G-CHF study (Global Congestive Heart Failure). We compared standardized KCCQ-12 summary scores (adjusted for age, sex, and markers of HF severity) among regions (scores range from 0 to 100, with higher score indicating better HRQL). We used multivariable Cox regression with adjustment for 15 variables to assess the association between KCCQ-12 summary scores and the composite of all-cause death, HF hospitalization, and each component over a median follow-up of 1.6 years.

Results: The mean age of participants was 65 years; 61% were men; 40% had New York Heart Association class III or IV symptoms; and 46% had left ventricular ejection fraction ≥40%. Average HRQL differed between regions (lowest in Africa [mean± SE, 39.5±0.3], highest in Western Europe [62.5±0.4]). There were 4460 (19%) deaths, 3885 (17%) HF hospitalizations, and 6949 (30%) instances of either event. Lower KCCQ-12 summary score was associated with higher risk of all outcomes; the adjusted hazard ratio (HR) for each 10-unit KCCQ-12 summary score decrement was 1.18 (95% CI, 1.17-1.20) for death. Although this association was observed in all regions, it was less marked in South Asia, South America, and Africa (weakest association in South Asia: HR, 1.08 [95% CI, 1.03-1.14]; strongest association in Eastern Europe: HR, 1.31 [95% CI, 1.21-1.42]; interaction <0.0001). Lower HRQL predicted death in patients with New York Heart Association class I or II and III or IV symptoms (HR, 1.17 [95% CI, 1.14-1.19] and HR, 1.14 [95% CI, 1.12-1.17]; interaction =0.13) and was a stronger predictor for the composite outcome in New York Heart Association class I or II versus class III or IV (HR 1.15 [95% CI, 1.13-1.17] versus 1.09 [95% CI, [1.07-1.11]; interaction <0.0001). HR for death was greater in ejection fraction ≥40 versus <40% (HR, 1.23 [95% CI, 1.20-1.26] and HR, 1.15 [95% CI, 1.13-1.17]; interaction <0.0001).

Conclusion: HRQL is a strong and independent predictor of all-cause death and HF hospitalization across all geographic regions, in mildly and severe symptomatic HF, and among patients with preserved and reduced ejection fraction. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03078166.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.050850DOI Listing
June 2021

United in earnest: First pilot sites for increased surgical capacity for rheumatic heart disease announced by Cardiac Surgery Intersociety Alliance.

J Thorac Cardiovasc Surg 2021 Jun 8;161(6):2108-2113. Epub 2021 Apr 8.

Cardiac Surgery Intersociety Alliance. Electronic address:

Background: Rheumatic heart disease (RHD) affects more than 33,000,000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration On Access to Cardiac Surgery in the Developing World was published in August 2018, signaling the commitment of the global cardiac surgery and cardiology communities to improving care for RHD patients.

Methods: As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance (CSIA) was formed, the purpose of this article is to describe the history of the CSIA, its formation, ongoing activities, and future directions, including the announcement of selected pilot sites.

Results: The CSIA is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment, and publication of selection criteria for cardiac surgery centers to apply for CSIA support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care, and desire to engage in future research. Eleven applications were received for which three finalist sites were selected and site visits conducted. The two selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda).

Conclusions: Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the CSIA, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry, and government-will be necessary to improve access to life-saving cardiac surgery for RHD patients.
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http://dx.doi.org/10.1016/j.jtcvs.2020.11.183DOI Listing
June 2021

United in Earnest: First Pilot Sites for Increased Surgical Capacity for Rheumatic Heart Disease Announced by Cardiac Surgery Intersociety Alliance.

Ann Thorac Surg 2021 06 8;111(6):1931-1936. Epub 2021 Apr 8.

Cardiac Surgery Intersociety Alliance. Electronic address:

Background: Rheumatic heart disease (RHD) affects more than 33,000,000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration On Access to Cardiac Surgery in the Developing World was published in August 2018, signaling the commitment of the global cardiac surgery and cardiology communities to improving care for RHD patients.

Methods: As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance (CSIA) was formed, the purpose of this article is to describe the history of the CSIA, its formation, ongoing activities, and future directions, including the announcement of selected pilot sites.

Results: The CSIA is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment, and publication of selection criteria for cardiac surgery centers to apply for CSIA support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care, and desire to engage in future research. Eleven applications were received for which three finalist sites were selected and site visits conducted. The two selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda).

Conclusions: Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the CSIA, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry, and government-will be necessary to improve access to life-saving cardiac surgery for RHD patients.
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http://dx.doi.org/10.1016/j.athoracsur.2020.11.043DOI Listing
June 2021

SARS-CoV 2 Infection (Covid-19) and Cardiovascular Disease in Africa: Health Care and Socio-Economic Implications.

Glob Heart 2021 03 15;16(1):18. Epub 2021 Mar 15.

Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, ZA.

The current pandemic of SARS-COV 2 infection (Covid-19) is challenging health systems and communities worldwide. At the individual level, the main biological system involved in Covid-19 is the respiratory system. Respiratory complications range from mild flu-like illness symptoms to a fatal respiratory distress syndrome or a severe and fulminant pneumonia. Critically, the presence of a pre-existing cardiovascular disease or its risk factors, such as hypertension or type II diabetes mellitus, increases the chance of having severe complications (including death) if infected by the virus. In addition, the infection can worsen an existing cardiovascular disease or precipitate new ones. This paper presents a contemporary review of cardiovascular complications of Covid-19. It also specifically examines the impact of the disease on those already vulnerable and on the poorly resourced health systems of Africa as well as the potential broader consequences on the socio-economic health of this region.
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http://dx.doi.org/10.5334/gh.829DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977038PMC
March 2021

United in earnest: first pilot sites for increased surgical capacity for rheumatic heart disease announced by cardiac surgery intersociety alliance.

Eur J Cardiothorac Surg 2021 06;59(6):1139-1143

Cardiac Surgery Intersociety Alliance, Chicago, IL, USA.

Objectives: Rheumatic heart disease (RHD) affects >33 000 000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration on Access to Cardiac Surgery in the Developing World was published in August 2018, signalling the commitment of the global cardiac surgery and cardiology communities to improving care for patients with RHD.

Methods: As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance (CSIA) was formed, the purpose of this article is to describe the history of the CSIA, its formation, ongoing activities and future directions, including the announcement of selected pilot sites.

Results: The CSIA is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment and publication of selection criteria for cardiac surgery centres to apply for CSIA support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care and desire to engage in future research. Eleven applications were received for which 3 finalist sites were selected and site visits conducted. The 2 selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda).

Conclusions: Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the CSIA, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry and government-will be necessary to improve access to life-saving cardiac surgery for patients with RHD.
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http://dx.doi.org/10.1093/ejcts/ezab145DOI Listing
June 2021

United in earnest: First pilot sites for increased surgical capacity for rheumatic heart disease announced by Cardiac Surgery Intersociety Alliance.

Asian Cardiovasc Thorac Ann 2021 Apr 8:2184923211005667. Epub 2021 Apr 8.

Background: Rheumatic heart disease affects more than 33,000,000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration on Access to Cardiac Surgery in the Developing World was published in August 2018, signaling the commitment of the global cardiac surgery and cardiology communities to improving care for rheumatic heart disease patients.

Methods: As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance was formed, the purpose of this article is to describe the history of the Cardiac Surgery Intersociety Alliance, its formation, ongoing activities, and future directions, including the announcement of selected pilot sites.

Results: The Cardiac Surgery Intersociety Alliance is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment, and publication of selection criteria for cardiac surgery centers to apply for Cardiac Surgery Intersociety Alliance support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care and desire to engage in future research. Eleven applications were received for which three finalist sites were selected and site visits conducted. The two selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda).

Conclusions: Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the Cardiac Surgery Intersociety Alliance, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry, and government-will be necessary to improve access to life-saving cardiac surgery for rheumatic heart disease patients.
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http://dx.doi.org/10.1177/02184923211005667DOI Listing
April 2021

Clinical characterization, cardiovascular risk factor profile and cardiac strain analysis in a Uganda cancer population: The SATRACD study.

PLoS One 2021 7;16(4):e0249717. Epub 2021 Apr 7.

Hatter Institute of Cardiovascular Research in Africa, Cape Town, South Africa.

Background: The link between cancer and cardiovascular disease is firmly established. We sought to investigate the prevalence of cardiovascular disease (CVD) risk factors in Uganda cancer patients, their pre-chemotherapy left ventricular strain echocardiographic pattern and its associations with the CVD risk factors.

Methods And Results: Baseline pre-chemotherapy data of patients who were enrolled in the SATRACD study (a cancer cohort, who were planned for anthracycline therapy), were analyzed. The prevalence of cardiovascular risk factors and baseline strain echocardiographic images were assessed. Among the 355 patients who were recruited over a period of 15 months, 283 (79.7%) were female, with a mean age of 43 years. The types of cancer of the study patients included breast cancer (70.6%), lymphomas, sarcomas, leukemias and hepatocellular carcinoma. Hypertension was the most common comorbidity (27.0%). The prevalence of obesity was 12.1% and that of HIV was 18.3%. All patients had a normal left ventricular ejection fraction (LVEF). The mean global longitudinal strain (GLS) was -20.92 ±2.43%, with females having a significantly higher GLS than males (-21.09±2.42 vs -20.25±2.39, p = 0.008). Fifty-three patients (14.9%) had suboptimal GLS (absolute GLS≤18.00%), which was associated with obesity (POR = 3.07; 95% CI, 1.31-6.98; p = 0.003), alcohol use (POR = 1.94; 95% CI, 1.01-3.74; p = 0.044), long QTc interval in electrocardiogram (POR = 2.54; 95% CI, 1.06-5.74; p = 0.015,) and impaired left ventricular relaxation (POR = 2.24; 95% CI, 1.17-4.25; p = 0.007). On multivariable logistic regression analysis, obesity (POR = 2.95; 95% CI, 1.24-7.03; p = 0.014) was the only independent factor associated with suboptimal GLS.

Conclusion: There is high prevalence and a unique pattern of cardiovascular risk factors in Uganda cancer patients. In cancer patients with cardiovascular risk conditions, there is reduction in GLS despite preserved LVEF. Longitudinal research is needed to study the predictive value of cardiovascular risk factors and baseline GLS for post chemotherapy cardiac dysfunction.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249717PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026039PMC
April 2021

Resting heart rate predicts all-cause mortality in sub-Saharan African patients with heart failure: a prospective analysis from the Douala Heart failure registry (Do-HF).

Cardiovasc Diagn Ther 2021 Feb;11(1):111-119

Department of Medicine, University of Cape Town, Cape Town, South Africa.

Background: Higher resting heart rate (HR) is associated with mortality amongst Caucasians with heart failure (HF), but its significance has yet to be established in sub-Saharan Africans in whom HF differs in terms of characteristics and etiologies. We assessed the association of HR with all-cause mortality in patients with HF in sub-Saharan Africa.

Methods: The Douala HF registry (Do-HF) is an ongoing prospective data collection on patients with HF receiving care at four cardiac referral services in Douala, Cameroon. Patients included in this report were followed-up for 12 months from their index admission, for all-cause mortality. We used Cox-regression analysis to study the association of HR with all-cause mortality during follow-up.

Results: Of 347 patients included, 343 (98.8%) completed follow-up. The mean age was 64±14 years, 176 (50.7%) were female, and median admission HR was 85 bpm. During a median follow-up of 12 months, 78 (22.7%) patients died. Mortality increased steadily with HR increase and ranged from 12.2% in the lower quartile of HR (≤69 bpm) to 34.1% in the upper quartile of HR (>100 bpm). Hazard ratio of 12-month death per 10 bpm higher HR was 1.16 (1.04-1.29), with consistent effects across most subgroups, but a higher effect in participants with hypertension . those without (interaction P=0.044).

Conclusions: HR was independently associated with increased risk of all-cause mortality in this study, particularly among participants with hypertension. The implication of this finding for risk prediction or reduction should be actively investigated.
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http://dx.doi.org/10.21037/cdt-20-785DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944210PMC
February 2021

PASCAR and WHF Cardiovascular Diseases Scorecard project.

Cardiovasc J Afr 2021 Jan-Feb;32(1):47-56

Division of Cardiology, Department of Medicine, University of Cape Town/Groote Schuur Hospital, Cape Town, South Africa; Pan-African Society of Cardiology, Cape Town, South Africa (vice-president south) World Heart Federation, Geneva, Switzerland; Hatter Institute for Cardiovascular Research in Africa, Faculty of Health Sciences, University of Cape Town, South Africa.

Data collected by the Pan-African Society of Cardiology for the World Heart Federation's Cardiovascular Diseases Scorecard project in Africa are presented. We summarise the strengths, threats, weaknesses and priorities identified from the collected data for South Africa, which need to be considered in conjunction with the associated sections in the accompanying infographic. Data sets that were used include open-source data available online and government publications. In the section on priorities and the way forward, we highlight the multifactorial health challenges with which South Africa has had to deal and the progress that has been made.
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http://dx.doi.org/10.5830/CVJA-2021-002DOI Listing
March 2021

Risk stratification and management of women with cardiomyopathy/heart failure planning pregnancy or presenting during/after pregnancy: a position statement from the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy.

Eur J Heart Fail 2021 04 17;23(4):527-540. Epub 2021 Mar 17.

Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.

This position paper focusses on the pathophysiology, diagnosis and management of women diagnosed with a cardiomyopathy, or at risk of heart failure (HF), who are planning to conceive or present with (de novo or previously unknown) HF during or after pregnancy. This includes the heterogeneous group of heart muscle diseases such as hypertrophic, dilated, arrhythmogenic right ventricular and non-classified cardiomyopathies, left ventricular non-compaction, peripartum cardiomyopathy, Takotsubo syndrome, adult congenital heart disease with HF, and patients with right HF. Also, patients with a history of chemo-/radiotherapy for cancer or haematological malignancies need specific pre-, during and post-pregnancy assessment and counselling. We summarize the current knowledge about pathophysiological mechanisms, including gene mutations, clinical presentation, diagnosis, and medical and device management, as well as risk stratification. Women with a known diagnosis of a cardiomyopathy will often require continuation of drug therapy, which has the potential to exert negative effects on the foetus. This position paper assists in balancing benefits and detrimental effects.
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http://dx.doi.org/10.1002/ejhf.2133DOI Listing
April 2021

Rationale and design of the African Cardiomyopathy and Myocarditis Registry Program: The IMHOTEP study.

Int J Cardiol 2021 06 16;333:119-126. Epub 2021 Feb 16.

Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, USA.

Background: Heart failure (HF), the dominant form of cardiovascular disease in Africans, is mainly due to hypertension, rheumatic heart disease and cardiomyopathy. Cardiomyopathies pose a great challenge because of poor prognosis and high prevalence in low- and middle-income countries (LMICs). Little is known about the etiology and outcome of cardiomyopathy in Africa. Specifically, the role of myocarditis and the genetic causes of cardiomyopathy are largely unidentified in Africans.

Method: The African Cardiomyopathy and Myocarditis Registry Program (the IMHOTEP study) is a pan-African multi-centre, hospital-based cohort study, designed with the primary aim of describing the clinical characteristics, genetic causes, prevalence, management and outcome of cardiomyopathy and myocarditis in children and adults. The secondary aim is to identify barriers to the implementation of evidence-based care and provide a platform for trials and other intervention studies to reduce morbidity and mortality in cardiomyopathy. The registry consists of a prospective cohort of newly diagnosed (i.e., incident) cases and a retrospective (i.e., prevalent) cohort of existing cases from participating centres. Patients with cardiomyopathy and myocarditis will be subjected to a standardized 3-stage diagnostic process. To date, 750 patients have been recruited into the multi-centre pilot phase of the study.

Conclusion: The IMHOTEP study will provide comprehensive and novel data on clinical features, genetic causes, prevalence and outcome of African children and adults with all forms of cardiomyopathy and myocarditis in Africa. Based on these findings, appropriate strategies for management and prevention of the cardiomyopathies in LMICs are likely to emerge.
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http://dx.doi.org/10.1016/j.ijcard.2021.02.026DOI Listing
June 2021

Taking a Stand Against Air Pollution - The Impact on Cardiovascular Disease: A Joint Opinion from the World Heart Federation, American College of Cardiology, American Heart Association, and the European Society of Cardiology.

Glob Heart 2021 01 28;16(1). Epub 2021 Jan 28.

World Heart Federation, Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, University of Cape Town, ZA.

Although the attention of the world and the global health community specifically is deservedly focused on the COVID-19 pandemic, other determinants of health continue to have large impacts and may also interact with COVID-19. Air pollution is one crucial example. Established evidence from other respiratory viruses and emerging evidence for COVID-19 specifically indicates that air pollution alters respiratory defense mechanisms leading to worsened infection severity. Air pollution also contributes to co-morbidities that are known to worsen outcomes amongst those infected with COVID-19, and air pollution may also enhance infection transmission due to its impact on more frequent coughing. Yet despite the massive disruption of the COVID-19 pandemic, there are reasons for optimism: broad societal lockdowns have shown us a glimpse of what a future with strong air pollution measures could yield. Thus, the urgency to combat air pollution is not diminished, but instead heightened in the context of the pandemic.
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http://dx.doi.org/10.5334/gh.948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7845468PMC
January 2021

Renal outcomes and blood pressure patterns in diabetic and nondiabetic individuals at high cardiovascular risk.

J Hypertens 2021 Apr;39(4):766-774

Department of Nephrology and Hypertension, University Hospital, Friedrich-Alexander University, Erlangen, Germany.

Background: Diabetes and hypertension are risk factors for renal and cardiovascular outcomes. Data on the association of achieved blood pressure (BP) with renal outcomes in patients with and without diabetes are sparse. We investigated the association of achieved SBP, DBP with renal outcomes and urinary albumin excretion (UAE) in people with vascular disease.

Methods: In this pooled analysis, we assessed renal outcome data from high-risk patients aged 55 years or older with a history of cardiovascular disease, 70% of whom had hypertension, randomized to The Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial and to Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease trials investigating telmisartan, ramipril and their combination with a median follow-up of 56 months. Standardized office BP was measured every 6 months, estimated glomerular filtration rate (eGFR) and UAE at baseline, 2 years and study end. Associations of mean achieved BP on treatment were investigated on major renal outcomes including end-stage renal disease (ESRD), decline of eGFR by at least 40%, doubling of creatinine and the composites thereof and on UAE. Analyses were by Cox regression analysis, analysis of variance and Chi2-test. Of 30 937 patients with complete data, 19 450 patients without and 11 487 with diabetes were enrolled between 1 December 2001 and 31 July 2003 and followed until 31 July 2008. Data were pooled as the outcomes for telmisartan 80 mg/day (n = 2903) or placebo (n = 2907) for Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease and ramipril 10 mg/day (n = 8407), telmisartan 80 mg/day (n = 8386) or the combination of both (n = 8334) were similar.

Results: For both those with and without diabetes, the hazard ratios for the composites ESRD or doubling of serum creatinine (707 events overall) and ESRD or 40% eGFR loss (2371 events overall) reached a nadir at achieved SBP of 120 to less than 140 mmHg, and increased with higher and lower SBP with similar relative risk with or without diabetes. For example, risk for the former composite reached a hazard ratios 3.06 (confidence interval 1.90-4.92) with a mean achieved SBP more than 160 mmHg compared with 120 to less than 130 mmHg with diabetes and hazard ratios 2.14 (1.09-4.26) without diabetes. In contrast, the development of new microalbuminuria and macroalbuminuria (3002 and 846 events overall) associated linearly over the whole range of achieved SBP (apart from a slight increase in risk at SBP less than 120 mmHg only in those without diabetes). Absolute risks for the composite and albuminuria outcomes were consistently greater in those with diabetes as compared with without diabetes with high event rates over the whole SBP spectrum. The increased renal risk at low SBP was not related to a meaningful reduction of mandated study drugs or open label renin-angiotensin-aldosterone system inhibition.

Conclusion: In patients at high cardiovascular risk, SBP levels more than 140 mmHg and less than 120 are associated with increased risk for renal outcomes. Renal risk was greater in diabetes across the whole range of achieved SBP and DBP. These data suggest similar target BP range in patients with and without diabetes to prevent renal outcomes, a frequent complication in high-risk vascular patients.

Clinical Trial Registration: Clinical Trial registration: http://clinicaltrials.gov.Unique identifier: NCT00153101.
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http://dx.doi.org/10.1097/HJH.0000000000002697DOI Listing
April 2021

Taking a Stand Against Air Pollution-The Impact on Cardiovascular Disease: A Joint Opinion from the World Heart Federation, American College of Cardiology, American Heart Association, and the European Society of Cardiology.

J Am Coll Cardiol 2021 04 28;77(13):1684-1688. Epub 2021 Jan 28.

World Heart Federation, Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa.

Although the attention of the world and the global health community specifically is deservedly focused on the COVID-19 pandemic, other determinants of health continue to have large impacts and may also interact with COVID-19. Air pollution is one crucial example. Established evidence from other respiratory viruses and emerging evidence for COVID-19 specifically indicates that air pollution alters respiratory defense mechanisms leading to worsened infection severity. Air pollution also contributes to co-morbidities that are known to worsen outcomes amongst those infected with COVID-19, and air pollution may also enhance infection transmission due to its impact on more frequent coughing. Yet despite the massive disruption of the COVID-19 pandemic, there are reasons for optimism: broad societal lockdowns have shown us a glimpse of what a future with strong air pollution measures could yield. Thus, the urgency to combat air pollution is not diminished, but instead heightened in the context of the pandemic.
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http://dx.doi.org/10.1016/j.jacc.2020.12.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7970621PMC
April 2021

Taking a stand against air pollution - the impact on cardiovascular disease.

Eur Heart J 2021 Apr;42(15):1460-1463

World Heart Federation, Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, University of Cape Town, South Africa.

Although the attention of the world and the global health community specifically is deservedly focused on the COVID-19 pandemic, other determinants of health continue to have large impacts and may also interact with COVID-19. Air pollution is one crucial example. Established evidence from other respiratory viruses and emerging evidence for COVID-19 specifically indicates that air pollution alters respiratory defense mechanisms leading to worsened infection severity. Air pollution also contributes to co-morbidities that are known to worsen outcomes amongst those infected with COVID-19, and air pollution may also enhance infection transmission due to its impact on more frequent coughing. Yet despite the massive disruption of the COVID-19 pandemic, there are reasons for optimism: broad societal lockdowns have shown us a glimpse of what a future with strong air pollution measures could yield. Thus, the urgency to combat air pollution is not diminished, but instead heightened in the context of the pandemic.
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http://dx.doi.org/10.1093/eurheartj/ehaa1025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953955PMC
April 2021

Taking a Stand Against Air Pollution-The Impact on Cardiovascular Disease: A Joint Opinion From the World Heart Federation, American College of Cardiology, American Heart Association, and the European Society of Cardiology.

Circulation 2021 Apr 28;143(14):e800-e804. Epub 2021 Jan 28.

World Heart Federation (K.S.).

Although the attention of the world and the global health community specifically is deservedly focused on the COVID-19 pandemic, other determinants of health continue to have large impacts and may also interact with COVID-19. Air pollution is one crucial example. Established evidence from other respiratory viruses and emerging evidence for COVID-19 specifically indicates that air pollution alters respiratory defense mechanisms leading to worsened infection severity. Air pollution also contributes to comorbidities that are known to worsen outcomes among those infected with COVID-19, and air pollution may also enhance infection transmission due to its impact on more frequent coughing. Yet despite the massive disruption of the COVID-19 pandemic, there are reasons for optimism: broad societal lockdowns have shown us a glimpse of what a future with strong air pollution measures could yield. Thus, the urgency to combat air pollution is not diminished, but instead heightened in the context of the pandemic.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.120.052666DOI Listing
April 2021
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