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Dilated cardiomyopathy (DCM) is the third most common cause of heart failure, often associated with arrhythmias and sudden cardiac death if not controlled. Metabolic and/or environmental factors, such as alcohol abuse, obesity, diabetes and Chagas disease, alter glycoprotein glycosylation, can lead to DCM. Inherited genetic disease, such as the human congenital disorders of glycosylation (CDG), causes multi-system manifestations including DCM. Non-congenital changes in glycosylation are also occurred in humans with and in animal models of DCM and heart failure. However, mechanisms responsible for glyco-dependent DCM are not understood. Here we sought to investigate the impact of sialylation and N-glycosylation in cardiac function. Partial reduction of N-α2,3-sialylation achieved through ST3Gal4 deletion (ST3Gal4-/-) led to adult late-onset DCM. The DCM symptoms progressed gradually, developing thinner left ventricular walls and dilation of all four chambers by 18-month old, but with preserved systolic function. Transverse aortic constriction (TAC) was used as a chronic stressor on 16-20 week old mice to determine whether the ability of the ST3Gal4-/- heart to compensate against pathologic insult is compromised. TAC’d ST3Gal4-/- mice presented with insufficient hypertrophy and reduced systolic function that deteriorated into congestive HF within six weeks post-surgery, while constricted WT hearts remained well-adapted throughout (ejection fraction, ST3Gal4-/-=34±5.2%; WT =53.8±7.4%; p<0.05).Calcineurin expression was decreased in ST3Gal4-/- (compared to TAC’d WT), contributed to the maladaptation of TAC’d ST3Gal4-/-. In order to better understand the role of glycosylation on cardiac function, we generated a cardiomyocyte specific knockout (αMHC-Cre) of glycosyltransferase responsible for synthesizing complex and hybrid N-glycans, Mgat1, (Mgat1CKO). Similar to but much more severe than that observed in ST3Gal4-/-, Mgat1CKO developed early-onset of DCM, late adult mortality, severely impaired cardiac systolic and diastolic function and frequent arrhythmias. Marked sex-difference in cardiac phenotype was observed in this autosomal gene (Mgat1) deletion, with male Mgat1CKO more severely affected. Both ST3Gal4 and Mgat1 did not participate in murine cardiogenesis, evidenced by normal litter size, Mendelian distribution of genotypes, no septal defect or vessel deformation under autopsy or echocardiography. In conclusion, we provided here the first and direct evidence of desialylation-elicited idiopathic dilated cardiomyopathy (DCM), reporting the cardiac phenotype of ST3Gal4-/-and cardiac-specific knockout of Mgat1. Our data showed sialylation and complex N-glycosylation are essential for cardiac function, and reduced N-glycosylation or sialylation leads to DCM development, contractile dysfunction and arrhythmia.

Background Chronic Obstructive Pulmonary disease (COPD) is an under-diagnosed disease with a prevalence of approximately 10%, highly dependent on age and smoking habits. Comorbidities are common in COPD and of these, cardiovascular diseases (CVD) are the most common. COPD is the fourth leading cause of death globally, and CVD probably contribute to the high mortality. Within CVD, Ischemic Heart Disease (IHD) is the most common. It is highly clinically relevant to identify signs of ischemic heart disease, other cardiac conditions, and risk factors for CVD in COPD. Electrocardiogram (ECG) is a simple but still major diagnostic tool in clinical cardiology, including disturbances in the electric conduction system and ischemia. Due to the under-diagnosis of COPD, there is limited knowledge regarding the prevalence and prognostic impact of ECG abnormalities in COPD. Arterial stiffness is a risk factor for CVD, which has raised an increased interest, however not evaluated in population based studies of COPD. Aim The overall aim was to describe cardiovascular aspects on COPD, with a specific focus on arterial stiffness, prevalence and prognostic impact of ischemic ECG abnormalities and prolonged QT interval, by comparing subjects with and without obstructive lung function impairment in a population-based cohort. Methods The thesis is based on the Obstructive Lung Disease in Northern Sweden (OLIN) COPD study; a population-based longitudinal cohort study. During the years 2002-2004, all participants in clinical examinations from previously recruited large population-based cohorts were invited to re-examination including spirometry and a structured interview. All subjects with obstructive lung function impairment (n=993) were identified, together with 993 age and sex-matched referents without airway obstruction. The study population (n=1986) has been invited to annual examinations since 2005 including spirometry and structured interview. Papers I-III are based on data from 2005 when electrocardiogram (ECG) was recorded in addition to the basic program. All ECGs were Minnesota coded and QT-time was measured. Paper IV is based data from 2010 when non-invasive measurements of arterial stiffness, assessed as pulse wave velocity (PWV), was added to the program. Spirometric data were classified as normal lung function (NLF), restrictive spirometric pattern (RSP) and airway obstruction (COPD). The following spirometric criteria for COPD were used: post-bronchodilator FEV1/VC&lt;0.70 (papers I-IV, in paper III labelled GOLD-COPD) and lower limit of normal, LLN (LLN-COPD) (paper III). Spirometric classification of COPD severity was based on FEV1 % predicted as a continuous variable or according to the Global Initiative for Obstructive Lung Disease (GOLD), divided into GOLD 1-4. Results The prevalence of ischemic heart disease (IHD), both self-reported and assessed as probable and possible ischemic ECG abnormalities (I-ECG) according to the Whitehall criteria, was similar among subjects with NLF and COPD. The prevalence of both self-reported and probable (I-ECG) according to Whitehall increased by GOLD grade.  Among those with COPD, self-reported IHD was associated with disease severity, assessed as FEV1 % predicted also after adjustment for age and sex (paper I). In both COPD and NLF, those with I-ECG had a higher cumulative mortality over 5 years than those without I-ECG (29.6 vs. 10.6%, p&lt;0.001 and 17.1 vs. 6.3 %, p=0.001). When analysed in a multivariate model, the Mortality Risk Ratio (MRR, 95%CI) was increased for subjects with COPD and I-ECG (2.4, 1.5-3.9), and non-significantly so for NLF with I-ECG (1.65, 0.94-2.90), when compared to NLF without I-ECG.  When analyzed separately among subjects with COPD, the increased risk for death associated with I-ECG persisted independent of age, sex, BMI-class, smoking habits and disease severity assessed as FEV1 % predicted (1.89, 1.20-2.99). The proportion without reported IHD was high among those with I-ECG; 72.4% in NLF and 67.3% in COPD. The pattern was similar also among them; I-ECG was associated with an increased risk for death in COPD and non-significantly so in NLF (paper II). Mean corrected QT-time (QTc) and prevalence of QTc prolongation was higher in RSP than NLF but similar in NLF and GOLD-COPD. The prevalence of borderline as well as prolonged QTc increased by GOLD grade (test for trend p=0.012 for both groups). Of those with GOLD-COPD, 52% fulfilled the LLN-criterion (LLN-COPD). When comparing LLN-COPD and NLF, the pattern was similar as when comparing NLF and GOLD-COPD. The cumulative mortality over 5 years was higher among subjects with borderline and prolonged QTc than those with normal QTc in subjects with GOLD-COPD and LLN-COPD but not in NLF and RSP (paper III). Arterial stiffness, assessed as PWV, was higher in GOLD 3-4 compared to non-COPD (10.52 vs. 9.13 m/s, p=0.042). Reported CVD and age &gt;60 were both associated with significantly higher PWV in COPD as well as in non-COPD. In a multivariate model, GOLD 3-4 remained associated with higher PWV when compared with non-COPD, also when adjusted for sex, age group, smoking habits, blood pressure, reported CVD and pulse rate (paper IV). Conclusion In this population-based study, the prevalence of ischemic ECG abnormalities was similar among subjects with normal lung function and COPD, but increased by disease severity among subjects with COPD. Ischemic ECG abnormalities were associated with an increased mortality among subjects with COPD, independent of common confounders and disease severity, also among those without known heart disease. Whilst the prevalence of QTc prolongation was similar in NLF, COPD and LLN-COPD, it was associated with an increased mortality only in the COPD-groups. ECG is a simple non-invasive method and seems to identify findings of prognostic importance among subjects with COPD. Central arterial stiffness, a known risk factor for cardiovascular disease, was increased among subjects with severe and very severe COPD when compared to subjects without COPD independent of common confounders.

Background: Type 2 diabetes mellitus (T2DM) is a major health concern among Navajo Indians. Native Americans and Alaskan Natives (NA/AN) currently have the highest rates of T2DM in the United States (Indian Health Service, 2016). The rate of diabetes on the Navajo Indian reservation is 22% (Partnersinhealth.org, 2009). Major health concerns for patients with T2DM include cardiovascular complications. Treatment is essential to prevent high-risk complications such as, cardiovascular disease (CVD). Purpose: The purpose of this quality improvement project was to implement a clinical decision support tool (CDST) to increase primary care provider awareness of current American Diabetes Association (ADA) statin therapy guidelines. The first objective was to increase the prescription rates of statin medications by 10%. The second objective of this project was to increase the performance target rate by 10%. Setting: This project was implemented at the Gallup Indian Medical Center (GIMC) Family Medicine Clinic. GIMC is located in Gallup, New Mexico. Participants: Participants included primary care providers, six Medical Doctors, two Nurse Practitioners, and one Physician Assistant. Methods: An evidence based clinical support decision tool (CDST) was generated the ADA statin therapy guidelines. Participants were educated on these practice guidelines and the CDST. The CDST was implemented into the electronic health record (EHR) over a four-week period. The provider used the CDST as a point-of-care guide when prescribing statin therapy to those with T2DM. Results: There was a 0.5% increase in the GPRA performance rating at GIMC as well as a 10% increase in prescribed statin therapy medications. There were 253 newly prescribed statin medications during data collection. Conclusion: While this project did not result in significant improvement of statin therapy GPRA performance ratings, a new EHR tool that providers can use to improve patient care was implemented. One outcome was met, there was a 10% increase in statin medication prescriptions. Further studies and future PDSA cycles will be required for testing the effectiveness of CDSTs.

The relationship between nutrition and HIV is multifactorial. Nutrition counseling provided by a Registered Dietitian (RD) has the potential for improving disease risk outcomes for PLWH. To determine barriers to access nutritional counseling with an RD in PLWH, and evaluate the relationship of this counseling on dietary intake, nutritional status, cardiovascular disease (CVD), and HIV-disease outcomes. This is a cross-sectional study of a consecutive convenience sample of 130 PLWH on stable ART from the MASH cohort. After consenting, participants completed a survey on types and frequency of nutritional services received in the last 12 months, and on barriers to access these services. Participants were assigned to groups according to their responses. Demographics, anthropometries, dietary intake, medical history and laboratory information were obtained. The Alternative Healthy Eating Index (AHEI) scores were calculated after obtaining two 24-hour dietary recalls, and Nutribase and SPSS 20 were used for analyses. Mean age was 47.7 years, 62.0% were male and 77.0% were Black; 48% percent were seeing an RD, with 48.3% of those visiting an RD³4 times within the year. Frequently identified barriers to nutritional services were difficulty in keeping appointments (33.8%) location (24.6%) and lack of referrals (23.8%) by medical personnel. Lack of referral was associated with lower CD4 cell count (r=-0.2, P=0.029). Compared to those who did not visit an RD, participants who did had higher AHEI scores (34.7 vs. 29.2, P < 0.001), lower waist circumference (35.5 vs. 38.5 in., P=0.003), and BMI (26.0 vs. 28.8 kg/m2, P=0.019), with higher proportion of participants within the normal range of BMI (48% vs. 25%, P=0.017). The group consulting an RD had significantly lower risk factors for CVD, with better lipid profiles for all biomarkers, and lower waist circumference (35.5 vs. 38.5 inches, P = 0.003) and systolic blood pressure (114.8 vs. 127.9 mmHg, P < 0.001). Other CVD risk factors such as ART and substance abuse, common in this population, were not significantly different between the groups. Our findings suggest that consulting with an RD is associated with better nutritional status, dietary intake and lower risk factors for CVD.

Background: Lipoprotein(a) [Lp(a)] is composed of a low density-lipoprotein (LDL) particle and a glycoprotein molecule known as apolipoprotein(a) [apo(a)]. Apo(a) exists in several differently-sized isoforms and is responsible for the unique properties of Lp(a). Although Lp(a) has been known for the past 40 years its relationship with coronary heart disease (CHD) has not been characterized in sufficient detail. Whether Lp(a) causes CHD is not clear. Furthermore, the role of apo(a) isoform variation and other sources of Lp(a) heterogeneity (e.g., level of oxidized phospholipids) in Lp(a)-disease association has not been determined. Objectives: To characterize in detail the association of circulating Lp(a) levels with the risk CHD To assess the nature of Lp(a)-CHD association using an integrative genetic study To explore the role of Lp(a) heterogeneity in its association with CHD Data sources: 1. The Emerging Risk Factors Collaboration (ERFC) database (36 studies, 127,000 participants) 2. The European Prospective Investigation of Cancer – Norfolk (EPIC-Norfolk) study (2200CHD cases, 2200 controls) 3. The Pakistani Risk of Myocardial Infarction Study (PROMIS) (1800 MI cases and 1800 controls) 4. Systematic quantitative reviews of published epidemiological studies Results: ERFC data - Analyses of cross-sectional data on up to 127,000 participants (predominantly of European descent) demonstrated that Lp(a) is generally not strongly correlated with known CHD risk factors. Weakly positive correlations were observed with LDL-cholesterol, apolipoprotein B100 and fibrinogen. Levels were over 2-fold higher in Blacks compared to Whites. Analyses of available data on repeat measurements in 6600 participants demonstrated that Lp(a) values have very high long-term within-person consistency (regression dilution ratio ~ 0.9). Outcome data involved 9300 incident CHD events, 1900 ischaemic strokes and 8100 nonvascular deaths. The risk ratio for CHD per 1SD higher Lp(a) concentration, adjusted for age, sex, lipids and other conventional vascular risk factors, was 1.13 (95% CI, 1.09-1.18). The corresponding risk ratios for ischaemic stroke and nonvascular death were 1.10 (1.02 – 1.18) and 1.01 (0.98-1.05), respectively. Data were too limited to assess association in nonwhites. PROMIS data – the adjusted odds ratio for MI in South Asians was comparable to that of Europeans. EPIC-Norfolk genetic data - The odds ratio for CHD per 1-SD higher Lp(a) concentration, after adjustment for cardiovascular risk factors, was 1.37 (1.20-1.56). Tagging SNPs rs10455872 and rs11751605 (minor allele frequency: 8% and 18%, respectively) were associated with 207% (95% CI, 188 - 227%) and 38% (31 - 46%) higher Lp(a) concentrations per copy of minor allele, respectively. These SNPs accounted for 35% and 5% of the variation in circulating Lp(a) levels, respectively, and were associated with an odds ratio for CHD of 1.34 (1.14-1.58) and 1.17 (1.04-1.33), respectively. The observed SNP-CHD associations were consistent with expected odds ratios corresponding to the Lp(a) effect of the SNPs. Systematic reviews – meta-analysis of published data from 40 studies (11,300 cases, 47,000 controls) demonstrated that people with smaller apo(a) isoforms have about a 2-fold higher risk of CHD or ischemic stroke than those with larger isoforms. Meta-analysis of published data from 10 studies (1500 cases, 10,200 controls) showed that people in the top third of baseline distribution of oxidized LDL levels have a 1.8-fold higher risk of CHD than those in bottom third. EPIC-Norfolk biomarker data – Levels of oxidized phospholipids were strongly correlated with Lp(a) concentration (r = 0.7, p-value < 0.0001). One SD higher concentration of oxidized phospholipids was associated with an adjusted odds ratio for CHD of 1.31 (1.15-1.49). The risk ratio was no longer significant after adjustment for Lp(a) concentration (1.08; 95% CI, 0.91-1.29). Conclusion: Lp(a) concentration is specifically, continuously and independently associated with the risk of ischaemic vascular outcomes. Available evidence supports the causal role of the particle in CHD. Lp(a) appears to induce vascular damage through causal mechanisms that involve apo(a) isoforms and oxidized phospholipids. A comprehensive study of markers of Lp(a) heterogeneity should help to understand the full impact of Lp(a) on cardiovascular diseases. In addition, further study is needed in nonwhites to assess the relevance of the factor to vascular disease risk in these populations.

Effective risk communication is essential in the field of health to ensure patients understand the information being presented to them by medical professionals and appreciate the level of risk involved in treatments. Cardiovascular disease, being the leading cause of death worldwide, is relevant to consider when examining risk communication in a health setting. Those afflicted with cardiovascular ailments are both high in number and exposed to information communicating risk. This research aims to identify presentation formats that are more effective communicating risk information to recovering cardiovascular patients at the University of Ottawa Heart Institute. The formats’ effectiveness is measured by gauging the population’s understanding of the material and perception of the information as it relates to risk and motivation. The research draws on Max Weber’s concept of rationality and subsequent scholars who developed social judgment theory, the heuristic-systematic model, expected utility theory, protection motivation theory, and the extended parallel process model. Utilizing an experimental research design, risk information handouts and questionnaires are distributed to, and completed by, a stratified sample of cardiovascular disease patients. Effective presentation formats are examined, and the results identify comparatively effective presentation formats for minimizing and maximizing risk perception. The results also identify presentation formats’ impact on a patient’s level of motivation to avoid / indulge in behaviours that may maximize or minimize risk. The results, synthesized herein, suggest a model (communicative cardiovascular physician-patient model of message preparation-perception), which may contribute to the effectiveness of risk communication between physicians and cardiovascular disease patients.

Elevated Thyroid-Stimulating Hormone (TSH) is associated with an increased risk of cardiovascular disease (CVD). We hypothesized that TSH-stimulated FA release from adipocytes contributes to macrophage inflammation. 3T3-L1 and human subcutaneous differentiated adipocytes were treated with TSH for 4 hours under various conditions and lipolysis assessed via glycerol secretion. Optimal conditions were determined and protein expression of ATGL, HSL and perilipin remained stable. TSH-stimulated 3T3-L1 or human adipocyte-conditioned medium (T-ACM) was placed on murine J774 or human THP-1 macrophages, respectively, and macrophage cytokine mRNA levels (IL-1β, IL-6, MCP-1, and TNFα) were measured by real-time RT-PCR. T-ACM did not change cytokine mRNA expression in J774 macrophages or THP-1 macrophages when compared to ACM. Absence of BSA in the medium may have hindered release of FA from differentiated adipocytes into the medium, BSA may be required to permit adequate FA accumulation in the medium to then evaluate the effect of T-ACM on macrophages. Further investigation is required to determine the effect of FA on J774 and THP-1 inflammatory response.

The expanding field of tissue engineering provides a new approach to regenerative medicine for common ailments such as cardiovascular disease and type-I diabetes. Biomaterials can be administered as a delivery vehicle to introduce therapeutic cells to sites of damaged or diseased tissue. A specific class of biomaterials, termed hydrogels, is suitable for this application as they can provide a biocompatible, biodegradable scaffold that mimics the physical properties of the native soft tissue. Injectable hydrogels are increasingly being developed for biomedical applications due to their ability to be delivered in a minimally invasive manner. One potential use for such materials is in the delivery of therapeutics such as cells or growth factor-releasing particles. In this study, the first aim was to determine the interactive effects between collagen-based hydrogels and additives (cells and microspheres) for cardiac regeneration. The results demonstrated that the addition of either cells or microspheres to a collagen-based hydrogel decreased its gelation time and increased its viscosity. Increased cross-linker concentrations resulted in lower cell viability. However, this cell loss could be minimized by delivering cells with the cross-linker neutralizing agent, glycine. As a potential application of these materials, the second aim of this study was to develop a hydrogel for use as an ectopic islet transplant site. Specifically, collagen-chitosan hydrogels were synthesized and characterized, with and without laminin, and tested for their ability to support angiogenic and islet cell survival and function. Matrices synthesized with lower chitosan content (20:1 collagen:chitosan) displayed greater cell compatibility for both angiogenic cells and for islets and weaker mechanical properties, while matrices with higher chitosan content (10:1 collagen:chitosan) had the opposite effect. Laminin did not affect the physical properties of the matrices, but did improve angiogenic cell and islet survival and function. Overall the proposed collagen-based hydrogels can be tailored to meet the physical property requirements for cardiac and islet tissue engineering applications and demonstrated promising cell support capabilities.