The scale of the blind spot is considerable. Population studies and meta-analyses cited by the group show that MASLD increases the risk of fatal and non-fatal cardiovascular events, new-onset heart failure, and atrial fibrillation. One recent meta-analysis of around 11 million individuals linked fatty liver disease to a significantly elevated risk of incident heart failure, and biopsy-proven cohorts have revealed that incident heart failure is both common and frequently missed in these patients. The group describes a global cardiovascular–liver–metabolic ‘syndemic’, in which shared risk factors such as obesity, type 2 diabetes and dyslipidaemia drive parallel epidemics of liver fibrosis and cardiovascular disease. When each speciality manages only its own organ, patients fall through the gaps, interventions arrive late, and outcomes suffer on both fronts.

At the mechanistic level, the liver and the heart are locked in bidirectional dialogue. The steatotic liver acts as an endocrine and inflammatory organ, exporting excess very-low-density lipoproteins, pro-inflammatory cytokines and other mediators that promote endothelial dysfunction, atherosclerosis and myocardial remodelling. Hepatic insulin resistance aggravates systemic metabolic dysfunction, while emerging proteomic work suggests that distinct organ-damage signatures can flag MASLD patients at risk of systemic complications before overt disease develops. Conversely, cardiac dysfunction feeds back on the liver: elevated central venous pressure in heart failure congests the hepatic circulation, and experimental evidence shows that myocardial infarction can accelerate steatohepatitis by triggering immunoinflammatory responses. Recent research also suggests that low-to-moderate alcohol intake and hypertension both amplify fibrosis progression in MASLD, tightening the links between metabolic, hepatic and cardiac trajectories.

A central tenet of the recommendation is that liver fibrosis, rather than simple steatosis, is the pivotal risk stratifier. Fat in the liver alone carries a more modest prognostic signal; the accumulation of fibrous scar tissue is what tracks with hepatic decompensation, cardiovascular events and mortality. The authors therefore propose that the degree of fibrosis should guide not only hepatological monitoring but also cardiovascular risk assessment, effectively serving as a shared currency between the two disciplines. Data from the global burden of disease project and longitudinal cohort analyses indicate that fibrosis stage predicts clinical events across the MASLD spectrum, including in so-called lean individuals, and that patients with coexisting cardiovascular–kidney–metabolic syndrome progress to advanced fibrosis and liver-related events more rapidly.

To operationalise this insight, the paper lays out a stepwise screening algorithm designed for real-world efficiency. First-line assessment uses the fibrosis-4 index, a simple calculation from age, aminotransferases, platelet count and aspartate aminotransferase that can be computed in any clinic. Patients flagged by this inexpensive test proceed to vibration-controlled transient elastography, a non-invasive ultrasound-based measurement of liver stiffness, and those with concerning results are referred for specialist evaluation. This cascade, the authors argue, enables identification of clinically significant fibrosis and high-risk metabolic phenotypes without resorting to liver biopsy in most patients, and it aligns with recent European screening studies that found previously unrecognised liver fibrosis to be common in the general population. The same non-invasive tools can be deployed longitudinally, since changes in stiffness and fibrosis markers over time carry prognostic information for both organ systems.

On the therapeutic front, the framework recommends pairing intensive lifestyle intervention with cardiometabolic drug classes that deliver dual liver and cardiovascular benefits. Glucagon-like peptide 1 receptor agonists have now demonstrated histological improvement in steatohepatitis in phase 3 trials of semaglutide and tirzepatide, alongside established reductions in major adverse cardiovascular events, heart failure hospitalisation and, for tirzepatide, benefit in obesity-related heart failure with preserved ejection fraction. Sodium–glucose cotransporter 2 inhibitors similarly combine cardiovascular and renal protection with emerging evidence of reduced liver-related events and mortality in patients with MASH cirrhosis. Meanwhile, resmetirom, the first approved liver-directed therapy for MASH with moderate to advanced fibrosis, addresses the hepatic side of the equation and has gained regulatory approval in both the United States and Europe. Statins, the authors add, remain underused in MASLD despite evidence of multisystem benefit and reassuring hepatic safety.

The recommendation does not stop at individual drugs; it embeds them within a structured metabolic care framework that treats the patient as a cardiometabolic whole. Data-driven cluster analyses and polygenic risk scores now identify biologically distinct MASLD subtypes, some predisposed to severe fibrosis and others to cardiometabolic complications, offering a route to precision-matched therapy. The authors argue that cardiovascular risk calculators such as SCORE2 and the American Heart Association’s PREVENT equations should be complemented by markers that capture the MASLD-specific burden, including high-sensitivity C-reactive protein, lipoprotein(a), inflammation indices and non-invasive fibrosis measures. They also stress aggressive management of hypertension, diabetes and dyslipidaemia, careful attention to alcohol consumption, and recognition that cardiovascular events themselves accelerate liver disease progression.

Implementation, the group acknowledges, is the hardest part. Quality-standards audits in the United Kingdom have documented wide variation in fatty liver disease care delivery, and therapeutic inertia remains endemic in cardiovascular prevention. The paper therefore proposes concrete pathways: bidirectional referral arrangements in which cardiologists screen for MASLD using FIB-4 and hepatologists routinely assess cardiovascular risk; shared care clinics and multidisciplinary teams; embedded non-invasive liver measures in both cardiology and hepatology workflows; and co-management protocols that specify who monitors what, and when. Clinical trials, they contend, should likewise embed dual hepatic and cardiovascular endpoints, a roadmap recently elaborated for multiorgan trial design spanning the MASLD–MASH–cardiovascular–kidney–metabolic spectrum. Without such integration, the benefits of newly available therapies risk accruing to the minority of patients who already navigate both specialities successfully.

The paper’s broader message is a reframing of MASLD itself: from an incidental imaging finding, or a condition waiting for cirrhosis, to a systemic metabolic disease whose most lethal complication is often cardiac. With global projections suggesting the MASLD burden will continue to climb through 2050, and cause-specific mortality data showing cardiovascular death outpacing liver-related death in these patients, the stakes of getting co-management right are high. The authors, whose work is supported by the CHAIN Consortium, position their expert recommendation as a practical bridge between cardiology and hepatology, one built on existing tools rather than speculative technology. If adopted, the framework could convert a fragmented two-organ problem into a single, coherent cardiometabolic care pathway, closing screening gaps, sequencing therapies by fibrosis stage and cardiovascular risk, and ultimately reducing the twin burdens of heart disease and liver failure in one of the world’s most common chronic conditions.

The shift in terminology itself reflects the evolving understanding of the disease. The multisociety Delphi consensus that introduced the MASLD nomenclature in 2023 deliberately replaced older terms to emphasise metabolic dysfunction as the unifying mechanism, and to allow coexistence with other hepatic conditions such as alcohol-associated liver disease. This reframing matters clinically, because the metabolic cluster that defines MASLD overlaps almost completely with the risk factors tracked by cardiovascular prevention guidelines, making the liver a natural target organ for cardiometabolic screening programmes.

Epidemiological data underpinning the recommendation are substantial. The Global Burden of Disease Study 2023 analysis projected continued growth in MASLD prevalence through mid-century, and systematic reviews have documented that hepatic and extrahepatic cancers, cardiovascular events and chronic kidney disease collectively account for a large share of adverse outcomes, with liver-related mortality no longer dominating the natural history except in advanced fibrosis. This changing pattern of mortality is precisely why the authors argue that risk stratification must serve two organ systems simultaneously.

The screening tools proposed also carry caveats worth noting. The fibrosis-4 index performs well at ruling out advanced fibrosis but has limited specificity, particularly in middle-aged patients with obesity or diabetes, where false positives are common and can drive unnecessary referrals. Vibration-controlled transient elastography offers better discrimination but can be unreliable in obesity and in acute hepatic inflammation, and access remains uneven across health systems. The stepwise algorithm therefore functions best as a triage instrument, reserving liver biopsy for indeterminate cases where the result would change management.

On the pharmacological side, the dual-benefit argument is supported by an expanding evidence base. Incretin-based therapies act on hepatic, adipose and central nervous system pathways that influence appetite, insulin sensitivity and hepatic fat flux, while sodium–glucose cotransporter 2 inhibitors shift myocardial metabolism and reduce cardiac congestion. Resmetirom, a selective thyroid hormone receptor-beta agonist, targets hepatic mitochondrial function and fat oxidation, complementing rather than replacing systemic metabolic therapy. The authors emphasise that sequencing these agents according to fibrosis stage and cardiovascular risk profile remains an open question that only trials with dual endpoints can resolve, reinforcing their call for co-management pathways embedded in routine practice.

Subject of Research: Heart–liver co-management and multidisciplinary cardiometabolic care in metabolic dysfunction-associated steatotic liver disease (MASLD)

Article Title: Heart–liver co-management in MASLD: expert perspectives and recommendations from a multidisciplinary cardiometabolic framework

Article References: Zhou, X.-D., Jeong, S., Chen, Q.-F., Targher, G., Byrne, C. D., Chew, N. W. S., Younossi, Z. M., Lip, G. Y. H., Tilg, H., George, J., Stefan, N., Sperling, L. S., Luu, H. N., Fudim, M., Loomba, R., & Zheng, M.-H. (2026). Heart–liver co-management in MASLD: expert perspectives and recommendations from a multidisciplinary cardiometabolic framework. Nature Reviews Gastroenterology & Hepatology. https://doi.org/10.1038/s41575-026-01255-z

Image Credits: AI Generated

DOI: 10.1038/s41575-026-01255-z

Keywords: MASLD, cardiovascular disease, liver fibrosis, heart–liver co-management, FIB-4, transient elastography, GLP-1 receptor agonists, SGLT2 inhibitors, resmetirom, cardiometabolic syndrome, risk stratification, multidisciplinary care

The study, led by Marie Payen de La Garanderie and Mathilde Touvier of the Nutritional Epidemiology Research Team at Université Sorbonne Paris Nord and Université Paris Cité, together with colleagues at INSEM, INRAE, CNAM and partner institutions including the International Agency for Research on Cancer, set out to address a fundamental blind spot in food safety science. Regulators such as the European Food Safety Authority and the U.S. Food and Drug Administration traditionally evaluate food additives one substance at a time, determining acceptable daily intakes for individual compounds. But consumers do not eat isolated additives in controlled doses. They eat packaged breads, sodas, processed meats, desserts and sauces that each contain a cocktail of several additives, and across a day’s diet, dozens of these substances interact in the digestive tract simultaneously. The new research represents one of the most ambitious attempts to capture that real-life exposure in an epidemiological framework.

The evidence base came from the NutriNet-Santé cohort, an ongoing web-based study of French adults launched in 2009 with follow-up extended to 2024. Participants in the analysis had a mean age of 42.8 years, with a standard deviation of 14.6, and 79 percent were women. A distinctive strength of the cohort lies in its dietary assessment method: rather than relying on generic food frequency questionnaires, participants completed up to three detailed 24-hour dietary records every six months. Crucially, these records captured the specific commercial brands of industrial products consumed. That brand-level detail allowed the researchers to reconstruct individual exposure to additives with unusual precision, using comprehensive food composition databases supplemented by ad-hoc laboratory analyses of actual food matrices to quantify the additive content of specific products.

To move beyond studying additives in isolation, the team employed Non-Negative Matrix Factorisation, an unsupervised machine-learning technique that identifies data-driven patterns of additives that co-occur in real diets. Rather than predefining which additives might cluster together, the algorithm extracted five recurring mixture profiles from the actual consumption data of more than one hundred thousand people. This approach ensured that the mixtures analyzed reflected genuine dietary patterns — the combinations a consumer of diet sodas, industrial cakes and processed convenience foods would actually be exposed to — rather than hypothetical pairings constructed by the researchers.

Participants’ health outcomes were then tracked through time. Over a median follow-up of 7.92 years, 5,543 participants developed hypertension, 2,450 developed some form of cardiovascular disease, 1,142 experienced a cerebrovascular accident such as a stroke, and 1,308 developed coronary heart disease. The researchers used multi-adjusted Cox proportional hazards models, treating exposure to the additive mixtures as time-dependent so that changes in diet over the years of follow-up were reflected in the analysis. Results were expressed as hazard ratios comparing participants in the highest tertile of consumption of each mixture with those in the lowest, adjusting for a wide range of potential confounders including overall diet quality, lifestyle factors and anthropometric characteristics.

The findings were striking for four of the five mixtures identified. Mixture 1, characterized mainly by sodium carbonates, diphosphates, glycerol and ammonium carbonates — additives typically found in baked goods and confectionery — was associated with a 14 percent higher incidence of hypertension (hazard ratio 1.14, 95 percent confidence interval 1.07–1.22) and a 12 percent higher incidence of cardiovascular disease overall (1.12, 1.00–1.24). Mixture 2, dominated by modified starches, pectin, guar gum and carrageenan, a suite of thickening and gelling agents ubiquitous in dairy desserts, plant-based drinks and processed sauces, showed associations with hypertension (1.12, 1.05–1.19), cardiovascular disease (1.18, 1.07–1.31) and, notably, the strongest single association in the study: a 26 percent increased incidence of coronary heart disease (1.26, 1.10–1.45).

Mixture 4, combining ammonium and sodium carbonates, diphosphates and alpha-tocopherol, was linked to elevated risks of hypertension (1.12, 1.05–1.19), cardiovascular disease (1.13, 1.02–1.26) and coronary heart disease (1.16, 1.01–1.34). Meanwhile, Mixture 5 — an acidic and sweetening cluster containing citric acid, sodium citrates, phosphoric acid and the artificial sweetener acesulfame-K, a profile strongly reminiscent of soft drinks — was associated with a 19 percent higher incidence of hypertension (1.19, 1.11–1.28), though it did not reach statistical significance for the broader cardiovascular endpoints. Only Mixture 3, composed of magnesium carbonates, riboflavin, alpha-tocopherol and ammonium carbonates, showed no detectable association with any of the studied outcomes.

Beyond the headline hazard ratios, the study’s exploratory analyses of interactions between emblematic additives within the mixtures point to something potentially more consequential: evidence of synergy. When two or more substances are present simultaneously, their combined effect may exceed the sum of their individual effects — a synergistic interaction — or, in some cases, one substance may dampen the effect of another, an antagonistic interaction. The researchers report several such interactions among additives composing the identified mixtures, supporting the hypothesis that the health impact of a food’s additive content cannot be predicted by testing each component separately. This resonates with a growing body of experimental work from toxicology laboratories, including work from co-authors at the Toxalim Research Centre in Food Toxicology in Toulouse, examining how combinations of emulsifiers and other additives affect the gut barrier, the intestinal microbiome and inflammatory pathways — mechanisms plausibly connected to hypertension and atherosclerosis.

The findings arrive amid intensifying scientific scrutiny of ultra-processed foods, which previous studies — many from the same NutriNet-Santé team — have linked to cardiovascular disease, cancer, type 2 diabetes and mortality. Food additives have long been suspected as one of the mediating factors behind those associations, but isolating their contribution has proven methodologically difficult. The present study adds an important layer: even within diets that may share a similar degree of processing, the specific cocktail of additives consumed appears to matter, and some cocktails are more strongly implicated in cardiovascular harm than others. The association with carrageenan and other emulsifier-type substances in Mixture 2, in particular, aligns with experimental evidence that certain emulsifiers can erode the protective mucus layer of the gut and promote low-grade inflammation.

The authors are careful to frame their conclusions appropriately. This is an observational study, and while the statistical models adjusted for numerous confounding factors, residual confounding — for example, by unmeasured lifestyle characteristics associated with both additive-rich diets and cardiovascular risk — cannot be entirely excluded. Hazard ratios in the range of 1.1 to 1.3 describe modest elevations in relative risk, though ones that could translate into substantial absolute public health impact given how widely these additives are consumed across populations. The cohort is also predominantly female and composed of volunteers who may be more health-conscious than the general population, factors that the authors note warrant replication in other, more diverse cohorts.

Nevertheless, the study is registered at ClinicalTrials.gov (NCT03335644), was conducted under Declaration of Helsinki guidelines with ethical approval from the French Institute for Health and Medical Research review board and the French data protection authority, and its funders — including a European Research Council Horizon 2020 grant dedicated specifically to studying food additives — played no role in the design, analysis or reporting. The work was published open access, and the authors declare no competing interests.

The implications for food policy could be considerable. If the effects of additives are genuinely interaction-dependent, then current regulatory frameworks, which establish acceptable daily intakes substance by substance, may systematically underestimate risk. The authors explicitly call for the consideration of mixtures in safety evaluations and for research into the underlying biological mechanisms. In the meantime, their recommendation to consumers is straightforward: limiting unnecessary food additives in the diet remains a prudent choice, and the findings lend fresh scientific weight to dietary guidance that favors minimally processed foods over the additive-laden products that now dominate supermarket shelves.Subject of Research: Associations between chronic exposure to real-life mixtures of food additives and the incidence of hypertension and cardiovascular disease in French adults

Coronary heart disease develops when fatty deposits and inflammatory processes narrow or obstruct the arteries supplying the heart. Even after treatment, patients remain vulnerable to recurrent symptoms, myocardial infarction, heart failure and complications that require hospital care. Exercise-based cardiac rehabilitation is designed to reduce that risk through supervised or prescribed physical activity, education, lifestyle support and clinical monitoring. Patients may train on treadmills, bicycles or through individually tailored walking programmes, with intensity adjusted according to symptoms, fitness and cardiovascular risk. The intervention can improve the ability of the heart, lungs, blood vessels and muscles to work together, but its effects are not limited to aerobic performance. It can also influence blood pressure, body composition, psychological wellbeing, medication adherence and everyday physical activity.

The CaReMATCH investigators used individual participant data rather than relying solely on summary results published by each trial. This approach allows researchers to analyse comparable variables across studies at the level of the individual patient, while accounting for differences in age, sex, baseline disease, treatment and starting fitness. It also makes it possible to investigate mediation. In statistical terms, mediation analysis asks whether an intervention affects an outcome partly because it changes an intermediate factor. For example, rehabilitation may reduce hospitalisation directly through broad physiological adaptation, but it may also reduce admissions indirectly by increasing exercise capacity, improving risk-factor control or helping patients remain physically active after the programme ends. The analysis therefore seeks to map the route from rehabilitation to hospitalisation rather than simply calculating an overall average effect.

The most important candidate mediator is exercise capacity, a measure of how much physical work a person can perform before fatigue, breathlessness or other limiting symptoms appear. It is commonly assessed through a cardiopulmonary exercise test, a symptom-limited exercise test or a functional walking assessment. Physiologically, improved capacity can reflect better cardiac output, more efficient oxygen delivery, improved endothelial function and greater ability of skeletal muscles to extract and use oxygen. These adaptations may allow patients to perform daily activities with less cardiovascular strain. Better fitness is also associated with improved reserve during illness, meaning that a patient may be more capable of tolerating an acute stress before complications become severe enough to require hospital admission. In the CaReMATCH framework, changes in functional capacity are examined as a potential bridge between participation in rehabilitation and later hospitalisation.

The analysis also considers a network of modifiable cardiovascular risk factors. Regular exercise can reduce resting and exertional blood pressure, improve insulin sensitivity and support healthier body composition. It may improve lipid metabolism and help patients adopt behaviours that strengthen the effects of prescribed cardiovascular medicines. Each of these pathways is biologically plausible. Lower blood pressure reduces mechanical stress on arterial walls; better glucose regulation can limit vascular damage; and improved lipid control may slow the progression of atherosclerotic plaque. However, mediation analysis is more demanding than simply observing that two variables improve at the same time. The investigators must assess whether a change in a risk factor occurs after rehabilitation, whether it is associated with hospitalisation, and how much of the intervention’s apparent effect remains after that factor is statistically taken into account.

Physical activity outside formal training is another potential link. A rehabilitation course may provide more than a temporary period of supervised exercise: it can teach patients how to judge intensity, manage symptoms and incorporate movement into ordinary life. This distinction matters because a few weeks of clinic-based exercise may not be enough to produce sustained protection if participants return to prolonged sitting and inactivity. Increased daily activity can reinforce improvements in fitness, weight, blood pressure and metabolic health. It may also reduce the loss of conditioning that often follows a cardiac event. By examining participant-level changes, the CaReMATCH study seeks to determine whether the benefits associated with rehabilitation are connected to what patients do after the structured programme as well as what happens during it.

Psychological and behavioural factors may contribute to the same chain. Anxiety, depression and fear of exertion are common after a heart attack or cardiac procedure, and they can lead patients to avoid activity even when exercise is medically safe. Rehabilitation programmes typically combine exercise with education, reassurance and contact with health professionals, helping patients distinguish normal exertional sensations from warning symptoms. Greater confidence may improve attendance, treatment adherence and willingness to remain active. These changes could influence hospitalisation indirectly by reducing symptom-related emergency visits or supporting long-term disease management. At the same time, the researchers treat such pathways cautiously because psychological measures are not always collected in the same way across trials, and mediation estimates can be sensitive to missing data and differences in follow-up.

A central message of the study is that no single measurement is likely to explain the entire association between exercise-based rehabilitation and hospitalisation. Cardiovascular adaptation, muscle conditioning, risk-factor modification, behaviour and psychological recovery overlap and reinforce one another. A patient who becomes fitter may also walk more, lose weight, sleep better and feel less anxious; separating these effects statistically is difficult because the mediators are not independent switches. The individual participant data design improves the analysis, but it does not turn observational pathways into definitive proof of causation. Mediation models rely on assumptions about timing, confounding and the accuracy of measurements. A factor may appear to mediate an outcome because it is linked to another unmeasured change, such as medication use, social support or access to continuing care.

Even with those limitations, the CaReMATCH findings have practical implications for the future of cardiac rehabilitation. If improvements in exercise capacity account for a substantial part of reduced hospitalisation risk, programmes may need to prioritise reliable fitness assessment and progression of training rather than simply recording attendance. If daily activity, psychological recovery or control of specific risk factors carries additional influence, rehabilitation could be made more personalised, combining exercise prescription with targeted support for inactivity, depression, blood pressure or metabolic health. The broader lesson is that rehabilitation should not be viewed as an optional add-on after acute cardiac treatment. It is a complex secondary-prevention strategy whose effects may emerge through several mutually reinforcing pathways. By identifying those pathways, the new analysis offers clinicians a clearer basis for designing programmes and gives patients a more vivid explanation of why regular, appropriately prescribed exercise can help keep them out of hospital.

Subject of Research: The mechanisms by which exercise-based cardiac rehabilitation influences hospitalisation risk in people with coronary heart disease.

Article Title: Mediators of the effect of exercise-based cardiac rehabilitation on hospitalisation risk in people with coronary heart disease – the CaReMATCH individual participant data meta-analysis

Article References: CaReMATCH individual participant data meta-analysis; published in the European Journal of Epidemiology.

Image Credits: AI Generated

DOI: 10.1007/s10654-026-01432-z

Keywords: coronary heart disease, cardiac rehabilitation, exercise therapy, hospitalisation, mediation analysis, individual participant data meta-analysis, cardiovascular prevention, exercise capacity, physical activity, secondary prevention

Exercise training is one of the central components of cardiac rehabilitation for people with coronary artery disease, including patients recovering from a heart attack, angioplasty, stent placement, or bypass surgery. Regular, supervised exercise can improve aerobic capacity, vascular function, quality of life, and long-term cardiovascular prognosis. Yet the response to training varies substantially between individuals. While many patients become fitter, a considerable proportion—often estimated at one in five or more—experience minimal change in peak oxygen uptake, commonly written as V̇O₂peak. This measurement reflects the maximum amount of oxygen the body can use during intense exercise and is considered one of the most important indicators of cardiorespiratory fitness. Low or unchanged V̇O₂peak is associated with poorer functional capacity and a higher risk of future cardiovascular complications.

The study included 353 patients with coronary artery disease who completed three to four weeks of inpatient cardiac rehabilitation. The participants had experienced a heart attack or undergone coronary procedures such as angioplasty or bypass surgery. At the beginning of rehabilitation, the research team collected data from cardiopulmonary exercise testing and pulse wave analysis, together with standard demographic and clinical information. Cardiopulmonary exercise testing measures how the heart, lungs, blood vessels, and muscles respond while a person exercises, typically on a bicycle or treadmill. Pulse wave analysis provides non-invasive information about the movement of pressure waves through the arteries, including pulse wave velocity, a widely used indicator of arterial stiffness. The researchers then used baseline information to predict whether each patient would achieve a clinically meaningful improvement in V̇O₂peak by the end of rehabilitation.

Ten machine-learning algorithms were evaluated, including approaches designed to identify complex and non-linear relationships among multiple clinical variables. The strongest results came from a Random Forest model, an ensemble method that combines the predictions of many decision trees. Each tree evaluates the data through a series of branching decisions, while the final model aggregates their outputs to produce a more stable prediction. This approach can be particularly useful in medical datasets where several biological factors interact and where a single variable rarely determines the outcome on its own. In this study, the model correctly classified responders and non-responders 77% of the time. Although that level of accuracy is not sufficient to replace clinical judgment, it suggests that routinely collected physiological data may contain signals that are invisible when patients are assessed using conventional risk factors alone.

The most surprising finding was that responders and non-responders appeared broadly similar at the start of rehabilitation when judged by standard clinical characteristics. Age, sex, body mass index, baseline fitness, and aspects of medical history did not reliably separate the two groups. Explainable artificial-intelligence analysis, using a technique known as SHAP, helped reveal which variables contributed most strongly to the model’s predictions. SHAP, or Shapley Additive Explanations, estimates how much each feature pushes an individual prediction toward one outcome or another. Rather than treating the algorithm as a black box, this method allows researchers to examine the relative influence of physiological measurements and understand why a particular patient may be predicted to respond poorly.

The most influential predictors were linked to breathing efficiency during exercise and the condition of the arteries. Patients who required more ventilation to consume a given amount of oxygen were less likely to achieve a substantial improvement in aerobic capacity. This relationship can be expressed through the ventilatory equivalent for oxygen, which describes how much air a person must move through the lungs for each unit of oxygen taken up by the body. A higher value may indicate that breathing is less efficient during exercise or that the circulation and respiratory systems are working under greater physiological strain. Reduced breathing reserve—the limited capacity remaining between exercise ventilation and the maximum ventilatory ability of the lungs—also contributed to predictions of a weaker training response.

Arterial stiffness provided another important signal. Patients with higher pulse wave velocity were less likely to improve their V̇O₂peak after standard rehabilitation. Healthy arteries expand and recoil as blood is pumped from the heart, helping regulate pressure and maintain efficient blood flow. Stiffer arteries transmit pressure waves more rapidly and can increase the workload placed on the heart while impairing the delivery of blood to working muscles. These vascular limitations may help explain why two patients with similar age, medical history, and baseline exercise capacity can respond very differently to the same training program. The model also identified the use of angiotensin II receptor blockers and calcium channel blockers as factors that influenced predictions, although the study does not establish that these medications directly caused a reduced response.

The findings suggest that the biology of exercise adaptation may be more individualized than traditional rehabilitation models assume. A standard aerobic program can produce strong benefits for many patients, but those with impaired vascular elasticity or inefficient ventilatory responses may require a different dose, intensity, duration, or progression of exercise. Instead of waiting until the end of rehabilitation to measure whether a patient has improved, clinicians could eventually use baseline pulse wave and exercise-test data to identify people who need closer monitoring or an adjusted program. Such interventions might include more carefully controlled aerobic intervals, longer training periods, additional resistance exercise, or treatment of underlying vascular and respiratory limitations. The researchers emphasize that the model is intended to support—not replace—medical decision-making.

Professor Boris Schmitz and Professor Frank Mooren of the University of Witten/Herdecke led the study in collaboration with researchers from DRV Clinic Königsfeld in Germany and FORTH in Greece. The team’s next step is a randomized controlled trial examining whether patients predicted to be non-responders can benefit from individually adjusted aerobic interval training. That experiment will be critical because prediction alone does not demonstrate that changing treatment will improve outcomes. A model may identify a group at higher risk of limited improvement, but only prospective testing can show whether acting on that information leads to greater gains in fitness, better symptoms, or improved cardiovascular health.

The researchers also caution that the current results should not yet be generalized to every cardiac rehabilitation population. The model was developed using patients treated in a specific clinical setting and may perform differently in older adults, people with multiple chronic conditions, or those completing outpatient programs with different exercise schedules. It will need external validation in larger and more diverse groups before it can be integrated into routine care. Even so, the study offers a compelling glimpse of how artificial intelligence could transform rehabilitation: not by replacing exercise, but by helping clinicians determine which kind of exercise is most likely to work for each patient. If future trials confirm the approach, a simple combination of cardiopulmonary exercise testing and pulse wave analysis could help prevent patients from completing rehabilitation without achieving meaningful improvements in cardiovascular fitness.

Subject of Research: People with coronary artery disease undergoing exercise-based cardiac rehabilitation

Article Title: A machine learning approach predicts improvement of physical exercise capacity based on pulse wave analysis in coronary artery disease patients

News Publication Date: 5 May 2026

Web References: https://doi.org/10.1016/j.jshs.2026.101144

References: Journal of Sport and Health Science; DOI: 10.1016/j.jshs.2026.101144

Image Credits: Hendrik Schäfer, University of Witten/Herdecke, Germany

Keywords: cardiac rehabilitation, coronary artery disease, machine learning, Random Forest, exercise response, non-responders, cardiopulmonary exercise testing, pulse wave analysis, arterial stiffness, V̇O₂peak, personalized medicine, cardiovascular health

Cardiac rehabilitation is a structured form of secondary prevention offered after conditions such as heart attack, coronary artery disease or other cardiovascular events. It typically combines physical activity, education, risk-factor management, medication support and psychological care. The goal is not only to help patients recover their physical capacity but also to reduce the likelihood of another cardiovascular event. Yet women are often less likely than men to begin or complete cardiac rehabilitation, and those living outside metropolitan areas can face additional barriers, including long travel distances, limited public transport, workforce shortages and a lack of programs designed around women’s experiences.

“The lack of women-focused programs are major barriers,” says Flinders University researcher Dr Joyce Ramos. “But home-based cardiac rehabilitation using telehealth and gender-tailored approaches may help address these challenges.” The CREW program was designed around this principle. Rather than requiring participants to attend repeated face-to-face sessions, it used a web-based format that allowed women to access educational material and rehabilitation support from home. Telehealth can reduce the practical burden of travel while maintaining contact with health professionals, an approach that may be particularly important in rural and remote regions where specialist services are widely dispersed.

The study included 40 women from rural or remote South Australia who had been referred to cardiac rehabilitation through the integrated Cardiovascular Clinical Network, known as iCCNet. Participants entered the study between November 2023 and November 2024 and were invited to use the CREW program. Its digital content consisted of four educational modules intended to strengthen self-management and help participants understand the factors influencing cardiovascular health. Completion was monitored through digital records, allowing researchers to assess how many women began the program and how many completed it.

The results indicated that 82.5 per cent of participants initiated cardiac rehabilitation, while 60 per cent completed the program. These figures are important because participation often declines between referral, enrolment and completion. A referral alone does not guarantee that a patient will receive the full benefits of rehabilitation. Completion can be affected by fatigue, pain, anxiety, family responsibilities, work demands, digital access and uncertainty about how rehabilitation fits into everyday life. The relatively high initiation rate in the CREW study suggests that a flexible, women-focused model may help reduce some of the obstacles that prevent patients from taking the first step.

Participants also reported high satisfaction with most elements of the program. Although satisfaction does not by itself demonstrate that a program improves long-term survival or prevents future cardiovascular events, it is a significant measure of feasibility and acceptability. Patients are more likely to engage with a health intervention when its format is understandable, accessible and relevant to their circumstances. A web-based platform may also give participants greater control over when and where they complete educational activities, which can be valuable for women balancing recovery with caregiving, employment or household responsibilities.

“ These findings highlighted the value of a women-focused approach to support women engage with their heart health,” says Dr Ramos. “They should also increase clinician awareness about the importance of recognising and addressing women’s unique needs throughout the cardiac rehabilitation journey.” Gender-sensitive rehabilitation does not mean assuming that every woman has the same needs. Instead, it recognises that cardiovascular disease can be shaped by differences in symptoms, life circumstances, social roles, communication preferences and access to care. A tailored program can provide space to address issues that may be overlooked in a general rehabilitation pathway, including confidence with physical activity, emotional recovery and the practical demands of managing health at home.

Researchers also conducted interviews with participating women and with clinicians responsible for delivering cardiac rehabilitation. These interviews added context to the digital participation data and explored how the program functioned in real-world conditions. The analysis identified several themes. Women described the program as empowering, particularly when it helped them develop knowledge and confidence in managing their cardiovascular health. Telehealth was viewed as a way to support participation by reducing travel and making rehabilitation more compatible with life in rural and remote communities. Clinicians, meanwhile, highlighted the potential of the model to respond to workforce and resource pressures within health systems.

The findings suggest that digital cardiac rehabilitation could extend specialist support without requiring every appointment to take place in a hospital or clinic. However, the researchers also identified opportunities to improve the program. Recommendations emerging from the interviews included enhancing program content and refining delivery so that it better reflects the experiences of women and the operational realities of clinicians. Digital programs must also account for differences in internet connectivity, technology confidence, health literacy and access to devices. A web-based intervention can remove geographic barriers, but it cannot eliminate every form of inequality unless technical and clinical support are built into its design.

The study does not establish that CREW produces better clinical outcomes than conventional cardiac rehabilitation, and its relatively small sample means the results should be interpreted as evidence of feasibility rather than definitive proof of effectiveness. Further research will be needed to determine whether the program improves physical fitness, medication adherence, cardiovascular risk factors, quality of life and long-term participation. Larger studies could also assess whether the approach is effective across different rural populations and whether it can be incorporated sustainably into routine health services. Even so, the combination of digital completion data and interviews provides a useful picture of how a women-focused model may work beyond the metropolitan health system.

The research, titled “Feasibility and Acceptability of the Cardiac Rehabilitation Especially for Women (CREW) Web-Based Program in Rural and Remote Communities: A Mixed-Method Study,” was conducted by Orathai Suebkinorn, Alline Beleigoli, Robyn Clark, Lemlem Gebremichael, Norma Bulamu, Jeroen Hendriks, Jonathon Foote, Anita Lymn, Sherry Grace and Joyce Ramos on behalf of the Cardiac Rehabilitation Especially for Women Project Team. Published in Heart, Lung and Circulation on 3 August 2026, the study presents CREW as a promising response to persistent gender and geographic disparities in cardiac rehabilitation. Its central message is that recovery after cardiovascular disease may be strengthened when care is brought closer to patients’ homes and designed with women’s real-world needs in mind.

Subject of Research: People

Article Title: Feasibility and Acceptability of the Cardiac Rehabilitation Especially for Women (CREW) Web-Based Program in Rural and Remote Communities: A Mixed-Method Study

Web References: https://doi.org/10.1016/j.hlc.2026.06.021

References: Suebkinorn O, Beleigoli A, Clark R, Gebremichael L, Bulamu N, Hendriks J, Foote J, Lymn A, Grace S, Ramos J, on behalf of the Cardiac Rehabilitation Especially for Women (CREW) Project Team. “Feasibility and Acceptability of the Cardiac Rehabilitation Especially for Women (CREW) Web-Based Program in Rural and Remote Communities: A Mixed-Method Study.” Heart, Lung and Circulation. Published 3 August 2026. DOI: 10.1016/j.hlc.2026.06.021

Keywords: cardiac rehabilitation, women’s cardiovascular health, telehealth, digital health, rural healthcare, remote communities, cardiovascular disease, secondary prevention, gender-tailored care, CREW program

NT-proBNP is a fragment released into the bloodstream when the heart muscle is stretched or placed under increased pressure. The hormone-related marker is widely used in clinical practice to help diagnose or evaluate heart failure, but concentrations can rise before a person develops obvious symptoms. Unlike conventional risk factors such as blood pressure, cholesterol, or smoking history, NT-proBNP can provide information about how the heart is responding physiologically to its workload. Elevated levels do not necessarily indicate overt heart failure, particularly in older adults, and can also be influenced by kidney function, age, rhythm disorders, and other medical conditions. In this study, the investigators treated the marker as an indicator of “heart stress,” reflecting possible early or hidden cardiac dysfunction rather than a disease diagnosis by itself.

The research team, led by scientists from Monash University and Shanghai Jiao Tong University School of Medicine, analyzed data from 8,454 adults aged 70 years or older. None had a history of cardiovascular disease when they entered the study. The participants were drawn from the ASPREE trial, a large investigation of whether low-dose aspirin could preserve health and prevent major disease in older adults, and from its follow-up extension. NT-proBNP concentrations were measured at enrollment and again approximately three years later. This design allowed researchers to examine not simply whether a participant’s value was high or low, but how the measurement changed over time.

Participants were classified into four groups according to their two NT-proBNP measurements. The persistently heart-stress-free group had no evidence of elevated levels at either visit. The heart-stress remission group had elevated NT-proBNP at enrollment but not at the three-year assessment. The incident heart-stress group began with levels that were not elevated and developed an elevated concentration by year three. The sustained heart-stress group had elevated levels at both time points. This longitudinal approach is important because biological risk is dynamic. A measurement taken on one day can be affected by temporary changes in health, whereas repeated results may better distinguish a lasting physiological signal from a transient abnormality.

Over a median follow-up period of eight years, participants with incident or sustained heart stress experienced higher risks of cardiovascular disease and death from any cause. The association was particularly concerning among people whose NT-proBNP became elevated during follow-up or remained high across both measurements, suggesting that newly emerging cardiac strain may be an important warning signal. In contrast, those in the remission group had risks comparable to participants whose levels stayed low. The result indicates that elevated NT-proBNP is not necessarily an irreversible forecast of poor health. Instead, the direction of change may carry valuable prognostic information, although the study cannot establish that lowering the marker itself will prevent heart attacks, heart failure, or death.

The findings are observational, meaning they show a relationship between patterns of NT-proBNP and later outcomes rather than proving that heart stress directly caused those outcomes. The participants were also generally healthy older adults enrolled in a clinical research setting, so the results may not apply identically to people with established cardiovascular disease, severe kidney disease, or significant symptoms. Even so, the size and duration of the analysis offer a detailed view of how a cardiac biomarker behaves before overt disease appears. The study’s repeated measurements also address a limitation of many risk-prediction models, which rely on one-time laboratory results and may overlook whether a biological abnormality is stable, worsening, or improving.

For clinicians, the work raises the possibility that NT-proBNP could become part of a broader strategy for assessing cardiovascular risk in older adults who feel well. A persistently elevated or newly rising result might prompt a closer review of blood pressure, kidney function, heart rhythm, physical activity, medication use, and symptoms that a patient has not recognized as significant. It could also encourage further evaluation with tools such as an electrocardiogram or echocardiogram when clinically appropriate. However, the researchers emphasize that heart stress should be interpreted as a marker of subclinical cardiac dysfunction, not as a therapeutic target in isolation. There is currently no basis for treating a laboratory value alone without understanding the underlying cause and the patient’s overall clinical context.

An accompanying editorial by Karen P. Alexander, MD, argues that population-based cohorts of asymptomatic older adults provide a rare opportunity to study both the prevalence and prognostic meaning of NT-proBNP before cardiovascular disease becomes clinically obvious. Dr. Alexander suggests that the marker could eventually contribute to wellness testing for older people because it may identify low but potentially modifiable risk while also offering a measure of biological aging. That possibility remains subject to further research. Before routine screening is adopted, investigators will need to determine how frequently NT-proBNP should be measured, which thresholds are most useful, how results should be combined with established risk scores, and whether biomarker-guided interventions actually improve outcomes.

The study arrives as researchers increasingly shift from static snapshots of health toward continuous or repeated measurements of biological change. In that framework, the most informative question may not be whether an older adult has elevated NT-proBNP today, but whether the heart is showing a sustained pattern of strain, developing a new abnormality, or returning to a lower-risk state. The results suggest that tracking these trajectories could improve long-term estimates of cardiovascular disease and mortality risk, potentially identifying vulnerable people before symptoms emerge. At the same time, the authors caution that NT-proBNP is a signal to investigate, not a diagnosis or a promise of future disease. More research will be needed to determine whether using changes in the marker to guide prevention can translate into longer, healthier lives for older adults.

Subject of Research: People

Article Title: Longitudinal Changes in Heart Stress and the Risk for Cardiovascular Disease and Mortality in Older Adults: An Observational Study

News Publication Date: 18-Aug-2026

Web References: https://www.acpjournals.org/doi/10.7326/ANNALS-26-00245

References: Annals of Internal Medicine, DOI: 10.7326/ANNALS-26-00245; accompanying editorial, DOI: 10.7326/ANNALS-26-02897

Keywords: NT-proBNP, heart stress, cardiovascular disease, mortality, older adults, cardiac dysfunction, biomarkers, heart failure risk, preventive medicine, ASPREE study

The study offers a striking picture of what smokers know—and what they do not. More than 90 percent of participants understood that smoking can cause lung cancer. However, only about 80 percent identified heart disease or heart attack as a consequence of smoking, while roughly 70 percent knew that smoking can cause stroke. These gaps are medically significant because cardiovascular disease accounts for a substantial proportion of tobacco-related deaths. Smoking is not simply an irritant that harms the lungs; it is a systemic exposure that alters blood vessels, promotes clot formation and accelerates the biological processes underlying heart attacks and strokes.

Tobacco smoke contains thousands of chemicals, including nicotine, carbon monoxide, fine particulate matter and numerous oxidizing compounds. Nicotine stimulates the sympathetic nervous system, increasing heart rate and blood pressure while contributing to dependence. Carbon monoxide binds to haemoglobin more readily than oxygen does, reducing the blood’s oxygen-carrying capacity. Other components injure the endothelium, the thin layer of cells lining blood vessels. Once this protective surface is damaged, inflammation and the accumulation of fatty plaques become more likely. Smoking also makes platelets more prone to clump together, increasing the chance that a disrupted plaque will produce a life-threatening clot.

These mechanisms help explain why tobacco exposure can trigger an acute cardiovascular event even in people who do not consider themselves heavy smokers. A heart attack generally occurs when blood flow through a coronary artery becomes severely restricted or blocked, while an ischemic stroke occurs when a clot prevents oxygen from reaching part of the brain. Smoking can contribute to both conditions by narrowing arteries, destabilizing arterial plaques and increasing coagulation. The danger is compounded when smoking is combined with other risk factors such as high blood pressure, diabetes, elevated cholesterol, obesity or physical inactivity. Yet the researchers found that these cardiovascular pathways have not become nearly as familiar to the public as the connection between cigarettes and lung cancer.

Awareness of second-hand smoke was even more troubling. In several high-income countries—including Australia, Germany, England, the United States, New Zealand and Canada—fewer than half of adult smokers knew that breathing other people’s tobacco smoke can cause heart disease or heart attack. China, home to approximately 300 million smokers, was among the countries where awareness was lowest. Second-hand smoke contains a complex mixture of sidestream smoke released from a burning cigarette and exhaled mainstream smoke. Even relatively brief exposure can impair vascular function, increase platelet activation and produce measurable changes in blood pressure and arterial stiffness, meaning that cardiovascular harm does not require years of active smoking.

The researchers examined trends across two decades and found little overall progress in knowledge about the health risks of smoking and second-hand smoke. Some countries, including Bangladesh, India, Thailand and Vietnam, recorded increased awareness of cardiovascular harms. In contrast, knowledge about the cardiovascular effects of second-hand smoke declined in most of the high-income countries included in the analysis, among them Canada, the United States, New Zealand, England and Japan. The result is particularly unexpected because many of these countries have implemented extensive tobacco-control programs. The findings suggest that progress in legislation does not automatically guarantee progress in public understanding, especially when health messages become less visible or fail to emphasize risks beyond lung disease.

Knowledge of second-hand smoke’s relationship to lung cancer also remained lower than knowledge about active smoking, with little improvement over time. This distinction matters because people who do not smoke may still be exposed at home, in vehicles, workplaces or other environments where tobacco smoke accumulates. Children, pregnant people, older adults and individuals with existing heart or lung conditions can be especially vulnerable. Although smoke-free laws reduce exposure in public settings, household exposure remains difficult to address without clear communication about its consequences. A message focused only on smell, discomfort or respiratory irritation may not convey that second-hand smoke can also affect the circulation and heart.

Dr. Janet Chung-Hall, a research scientist with the International Tobacco Control Policy Evaluation Project at Waterloo and lead author of the study, described the knowledge gaps as deeply concerning. She emphasized that smoking causes more than two million cardiovascular deaths worldwide each year, making the lack of awareness a major public-health problem rather than a minor communications failure. Dr. Geoffrey T. Fong, principal investigator of the ITC Project and a University Professor of Psychology and Public Health Sciences at Waterloo, said that knowledge is an important first step toward quitting and protecting others from second-hand smoke. Understanding risk does not guarantee behavior change, but it can strengthen motivation, increase receptiveness to cessation support and make tobacco-control policies more effective.

The researchers point to large pictorial health warnings and sustained mass-media campaigns as tools that could close the gap. Graphic warnings can communicate biological damage quickly, even when people do not read detailed text, while repeated campaigns can reinforce information that might otherwise fade from memory. Effective messaging would need to place cardiovascular disease alongside lung cancer, clearly explaining that smoking can cause heart attack and stroke and that second-hand smoke can harm the heart as well. The findings also support the broader implementation of measures contained in the World Health Organization Framework Convention on Tobacco Control, a global treaty with more than 180 signatory countries. As tobacco companies continue to market nicotine products across diverse populations, the study suggests that public education must remain persistent, scientifically precise and impossible to ignore.

Subject of Research: People

Article Title: Smokers still largely unaware of heart disease risks

News Publication Date: 4-Aug-2026

Web References: https://bmjopen.bmj.com/content/16/8/e107667

References: BMJ Open, DOI: 10.1136/bmjopen-2025-107667

Keywords: tobacco smoking, second-hand smoke, cardiovascular disease, heart attack, stroke, lung cancer, public health, tobacco control, health awareness, smoking cessation

Cardiovascular disease remains the leading cause of death worldwide, and its global burden has increased dramatically over recent decades. Cases nearly doubled between 1990 and 2019, driven by population growth, ageing, sedentary lifestyles and the continuing prevalence of conditions such as hypertension, obesity, diabetes and high cholesterol. Although structured exercise can improve cardiovascular fitness, many adults do not meet recommended activity levels because of limited time, poor access to facilities or the practical demands of daily life. Stair climbing offers a form of vigorous, weight-bearing activity that requires no membership, equipment or dedicated workout period. Each ascent briefly raises heart rate and breathing, activates large muscle groups in the legs and increases the body’s demand for oxygen.

The research team began by reviewing nearly 1,900 scientific studies examining the relationship between stair climbing and health outcomes. After applying quality and eligibility criteria, the investigators combined data from nine high-quality studies involving more than 480,000 participants. The participants ranged in age from 35 to 84 years, and 53 per cent were women. The study population included both people with no known cardiovascular disease and people with a previous history of heart problems, making the findings relevant to a broad range of adults. Participants were followed for a median of 14 years, allowing researchers to assess long-term associations between habitual stair use, cardiovascular events and mortality.

A meta-analysis does not conduct a new experiment on participants; instead, it statistically combines results from multiple studies to identify patterns that may be difficult to detect in any single investigation. In this case, the researchers compared outcomes among people reporting different levels of stair climbing. The consistency of the association across the included studies strengthened the signal: those who climbed stairs more frequently generally experienced fewer cardiovascular deaths and fewer deaths overall. However, the design cannot prove that stair climbing alone caused the reductions. People who choose stairs may also be more physically active in other ways, have healthier diets, smoke less, maintain healthier body weights or receive better preventive medical care. Researchers therefore interpret the findings as a strong association rather than definitive proof of a direct cause-and-effect relationship.

The biological explanation is plausible. Climbing stairs places a relatively high demand on the cardiovascular and musculoskeletal systems because the body must repeatedly lift its own weight against gravity. This increases cardiac output, the amount of blood the heart pumps each minute, while also challenging the muscles’ ability to extract and use oxygen. Repeated exposure to this stimulus can improve cardiorespiratory fitness, strengthen the leg muscles and enhance vascular function. Physical activity may also help regulate blood pressure, insulin sensitivity, blood lipid levels and body composition, all of which influence the development of atherosclerosis and other cardiovascular disorders. Even short bouts can produce temporary improvements in blood flow and metabolic activity, and repeated daily exposure may gradually build a meaningful training effect.

The researchers highlighted that stair climbing can be particularly valuable because it is easily incorporated into existing routines. A person may climb stairs at home, in an office, at a railway station, in a shopping centre or in a public building without setting aside a separate period for exercise. Unlike a conventional workout, it does not require changing clothes, travelling to a gym or following a formal training programme. For people with busy schedules, these small decisions may provide a realistic route toward greater daily activity. The research team said that even brief bursts of stair climbing should be considered an achievable target, particularly for adults who currently perform little or no structured exercise.

The amount of stair climbing associated with the greatest benefit remains uncertain. One large cohort study included in the analysis suggested that climbing approximately six flights per day may offer a particularly favourable balance between effort and health benefit. Other evidence indicated that higher levels of stair climbing were generally linked with greater improvements, although the relationship may not be perfectly linear. The studies differed in how they measured stair use, with some relying on participants’ memories and questionnaires rather than direct monitoring. A flight of stairs can also vary considerably in height, and the speed of ascent, number of steps and recovery time may influence the physiological response. These differences make it difficult to prescribe a single optimal “dose.”

Future research could address these limitations by using wearable activity monitors, smartphone sensors or other technologies capable of recording stair ascent more accurately. Such tools could help distinguish between occasional stair use and repeated, purposeful climbing, while also measuring intensity, duration and changes over time. Researchers may then be able to determine whether short, rapid ascents produce different benefits from slower climbing, whether the effects vary according to age or pre-existing disease, and how stair activity compares with walking, cycling or other forms of moderate-to-vigorous exercise. Randomised trials would provide stronger evidence about causality, although long-term trials assigning people to different daily stair routines would be difficult to conduct.

The findings do not mean that everyone should immediately begin climbing as many stairs as possible. People with significant mobility limitations, severe joint disease, balance problems or unstable heart symptoms may need to modify the activity or seek medical advice before increasing exertion. Stair climbing can place substantial stress on the knees, hips and cardiovascular system, particularly when performed quickly or by people who are not accustomed to it. For most adults, however, gradually choosing stairs over lifts when safe and practical may be a simple way to increase activity. The broader message is that cardiovascular protection may be built not only through formal exercise sessions but also through repeated choices made throughout the day. Published in the American Journal of Cardiovascular Drugs, the study suggests that an ordinary staircase could become a small but influential part of population-level strategies to prevent heart disease.

Subject of Research: People

Article Title: Evaluating the Impact of Stair Climbing on Cardiovascular Risk Reduction: A Systematic Review and Meta-analysis

News Publication Date: 13-Aug-2026

References: American Journal of Cardiovascular Drugs

Keywords: Stair climbing, cardiovascular disease, heart disease, cardiovascular mortality, premature death, physical exercise, public health, heart attack, stroke, heart failure, hypertension, cardiac function, human health, meta-analysis

BMI is calculated by dividing body weight in kilograms by height in meters squared. Although simple and inexpensive, the measure cannot show where fat is stored or distinguish fat from muscle. That limitation is important because abdominal fat, particularly visceral adipose tissue surrounding internal organs, is metabolically active and has been linked to insulin resistance, inflammation, high blood pressure and abnormal blood lipid levels. Subcutaneous fat beneath the skin appears to have weaker associations with cardiovascular disease, meaning that two people with identical BMIs may have very different biological risk profiles.

Researchers from the Cross Cohort Collaboration examined whether adding measurements of abdominal fat distribution to BMI could improve predictions of major cardiovascular outcomes. Participants had available WC or WHR data and were assessed for one or more of nine outcomes: fatal or nonfatal myocardial infarction, fatal or nonfatal stroke, heart failure, atrial fibrillation, total coronary heart disease, total cardiovascular disease, coronary heart disease mortality, cardiovascular disease mortality and all-cause mortality. The long follow-up allowed the investigators to evaluate whether body-fat distribution was associated with events that developed years after the initial measurements.

The study showed that central adiposity was present in a meaningful proportion of people whose BMI would traditionally place them in a lower-risk category. Among participants classified as normal weight by BMI, 5 percent had a high waist circumference and 18 percent had a high waist-to-hip ratio. In the overweight group, 39 percent had a high waist circumference and 40 percent had a high waist-to-hip ratio. These results suggest that a substantial number of people may carry elevated abdominal fat without being identified as at risk by BMI alone.

The implications were especially striking among people with normal weight or overweight. Those with a clinically high WC or WHR had a 15 to 50 percent greater risk for most of the nine outcomes compared with participants whose BMI and central-adiposity measures were in lower-risk ranges. The association persisted across several forms of cardiovascular disease, indicating that abdominal fat distribution may provide information beyond the broad weight categories used in routine medical practice.

The findings also complicated the assumption that obesity automatically identifies the people at greatest cardiovascular risk. Among participants with obesity, 9 percent had a low waist circumference and 45 percent had a low waist-to-hip ratio. Individuals with obesity but low WC were not significantly different in risk from normal-weight participants with low WC for most outcomes. The exception was all-cause mortality, for which the obesity group with low WC showed a significantly lower risk. Because the study was observational, however, these results do not establish that a smaller waist protects against disease or explain why different patterns appeared across BMI categories.

“Where fat is distributed matters,” said Michael J. Blaha, MD, MPH, senior author and director of clinical research at the Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease. He noted that waist circumference and waist-to-hip ratio appeared to reclassify risk defined by traditional BMI thresholds, including among people considered to have normal weight. Lead author Zeina A. Dardari, PhD, MS, said clinicians should consider central adiposity across the entire BMI spectrum when assessing cardiovascular risk in primary prevention.

Waist circumference is a direct measurement around the abdomen, while WHR compares waist size with hip size. Both are indirect markers of body-fat distribution and can be influenced by sex, age, ethnicity, body shape and measurement technique. Neither test can determine precisely how much visceral fat a person has; imaging methods such as computed tomography or magnetic resonance imaging are more specific but are expensive and impractical for routine screening. Nevertheless, the researchers argue that these simple anthropometric measurements can add clinically relevant information at low cost.

The study has important limitations. Researchers lacked detailed data on physical activity, diet and genetic susceptibility to obesity, all of which can influence cardiovascular disease. WC and WHR were measured only once, so the analysis could not determine how changes in abdominal fat over time affected risk. The findings also describe associations rather than direct cause-and-effect relationships. Even so, the scale and duration of the study support the view that BMI should be treated as one component of cardiovascular assessment rather than a complete measure of health risk. Adding waist-based measurements could help identify people whose apparent weight category conceals a more concerning pattern of fat accumulation.

Subject of Research: The relationship between body mass index, waist circumference, waist-to-hip ratio and long-term cardiovascular disease risk.

Article Title: Risk Reclassification Beyond BMI by Waist Circumference and Waist-to-Hip Ratio Across Nine Cardiovascular Outcomes: Results from the Cross-Cohort Collaboration

News Publication Date: 11-Aug-2026

Web References: Journal of the American College of Cardiology, DOI: 10.1016/j.jacc.2026.05.050

References: Dardari ZA et al., “Risk Reclassification Beyond BMI by Waist Circumference and Waist-to-Hip Ratio Across Nine Cardiovascular Outcomes: Results from the Cross-Cohort Collaboration,” Journal of the American College of Cardiology.

Keywords: cardiovascular disease, heart disease, body mass index, BMI, waist circumference, waist-to-hip ratio, central adiposity, visceral fat, obesity, cardiovascular risk, myocardial infarction, stroke, heart failure, atrial fibrillation

The study, published in JACC: Advances, addresses a major limitation in current cardiovascular medicine. Widely used risk calculators were largely developed in older populations and generally focus on factors such as age, blood pressure, cholesterol levels, smoking and diabetes. Although these measures are important, they do not fully capture health events and conditions that are specific to women. Pregnancy, in particular, can reveal biological and metabolic vulnerabilities that may later contribute to heart disease.

“Heart disease is the leading cause of death in women, yet existing risk tools were developed in older populations and ignore factors unique to women,” said senior author Robert Platt, Professor in McGill’s Department of Epidemiology, Biostatistics, and Occupational Health and Director of the School of Population and Global Health. The researchers say that pregnancy may function as an early-life stress test, exposing cardiovascular risk that might otherwise remain hidden for decades.

To build the model, the team analyzed health data from more than 260,000 women in the United Kingdom between the ages of 15 and 45 who had given birth. The participants were followed for nearly four years after delivery, allowing researchers to examine which medical, reproductive and social characteristics were associated with the emergence of cardiovascular disease during the early follow-up period. The model was then validated to assess how accurately it could distinguish women at comparatively higher and lower risk.

Among the strongest and most informative factors were complications that are already known to affect pregnancy outcomes but are not routinely incorporated into standard cardiovascular prediction tools. These included hypertensive disorders of pregnancy, such as gestational hypertension and pre-eclampsia, as well as gestational diabetes and preterm birth. Each of these conditions can reflect abnormalities in blood-vessel function, glucose regulation, inflammation or placental biology—processes that are also closely connected to future cardiovascular disease.

The model also incorporated a broader range of health and social variables. Polycystic ovary syndrome, depression, thyroid disorders, oral contraceptive use and social deprivation were among the factors identified as potentially useful for estimating future risk. Their inclusion reflects a more comprehensive view of cardiovascular health, in which reproductive history, mental health, endocrine function and living conditions can interact with traditional medical measurements.

The findings suggest that some women who would normally be considered too young for cardiovascular screening may already carry a meaningful level of risk. A woman who experiences high blood pressure during pregnancy, delivers prematurely or develops gestational diabetes may not have elevated cholesterol or a long history of hypertension immediately after giving birth. Yet these pregnancy-related events may signal underlying vascular or metabolic changes that deserve follow-up rather than being treated as isolated episodes that end at delivery.

“Millions of women who give birth each year are never considered candidates for cardiovascular risk assessment simply because of their age,” said co-author Kristian Filion, Professor in McGill’s Departments of Medicine and of Epidemiology, Biostatistics, and Occupational Health. If incorporated into routine postpartum care, the model could help clinicians decide which patients might benefit from repeated blood-pressure and metabolic monitoring, lifestyle counselling or referral to a cardiovascular specialist. Earlier intervention could, in principle, reduce the likelihood of a heart attack or stroke later in life.

The researchers emphasize that the tool is intended to estimate risk, not diagnose heart disease or replace clinical judgment. Its performance must also be tested in populations outside the United Kingdom before it can be used broadly. The next step is validation in Canada and the United States, where patterns of healthcare access, ethnicity, pregnancy care and social deprivation may differ. In the longer term, the team hopes to develop a practical calculator that can be integrated into electronic health records, allowing pregnancy complications and other woman-specific factors to trigger personalized cardiovascular prevention at a much younger age.

Subject of Research: People

Article Title: Development and Validation of a Prediction Model for Cardiovascular Risk in Reproductive-Aged Women

News Publication Date: 27-May-2026

Web References: https://www.jacc.org/doi/10.1016/j.jacadv.2026.102760

References: JACC: Advances. DOI: 10.1016/j.jacadv.2026.102760

Keywords: cardiovascular disease, women’s health, pregnancy complications, postpartum care, gestational diabetes, hypertensive disorders of pregnancy, preterm birth, polycystic ovary syndrome, cardiovascular risk prediction, preventive medicine, McGill University