There is increasing evidence that gum disease is associated with increased risk of cardiovascular events, including heart attack, stroke, atrial fibrillation, heart failure and cardiometabolic health conditions. Effective prevention and treatment of gum disease, also called periodontal disease, could potentially decrease the burden of cardiovascular disease, according to a new scientific statement published today in the American Heart Association’s flagship journal Circulation.

The new American Heart Association scientific statement, “Periodontal Disease and Atherosclerotic Cardiovascular Disease,” features new data supporting an association between periodontal disease and atherosclerotic cardiovascular disease (ASCVD) and updates the Association’s 2012 scientific statement. ACSVD, the leading cause of death globally, is caused by buildup of arterial plaque (fatty deposits in the arteries) and refers to conditions that include coronary heart disease, stroke, peripheral artery disease and aortic aneurysms.

“Your mouth and your heart are connected,” said Chair of the scientific statement writing group Andrew H. Tran, M.D., M.P.H., M.S., FAHA, a pediatric cardiologist and the director of the preventive cardiology program at Nationwide Children’s Hospital in Columbus, Ohio. “Gum disease and poor oral hygiene can allow bacteria to enter the bloodstream, causing inflammation that may damage blood vessels and increase the risk of heart disease. Brushing, flossing and regular dental checkups aren’t just about a healthy smile—they’re an important part of protecting your heart.”

Highlights of the statement include:

• Periodontal disease is a chronic inflammatory condition affecting over 40% of U.S. adults over age 30. The earliest stage is gingivitis (inflammation of the gums due to buildup of oral plaque). If left untreated, gingivitis may progress to periodontitis, where the gums begin to pull away from the teeth, forming small pockets that can trap bacteria and lead to infection. The most advanced stage, severe periodontitis, involves extensive damage to the bones supporting the teeth; teeth may become loose and fall out. This stage often requires surgical intervention. 
• Periodontal disease is more common in individuals with poor oral hygiene and other cardiovascular disease risk factors, such as high blood pressure, overweight or obesity, diabetes and smoking. The prevalence of periodontal disease is also higher among men, older adults, individuals with low physical activity and people affected by adverse social determinants of health, such as lower socioeconomic status, food insecurity and/or lack of access to health care including dental care.
• Although periodontal disease and ASCVD share common risk factors, emerging data indicates there is an independent association between the two conditions. Potential biological mechanisms linking periodontal disease with poor cardiovascular outcomes include direct pathways such as bacteria in the blood and vascular infections, as well as indirect pathways such as chronic systemic inflammation.
• Numerous studies have found that periodontal disease is associated with an increased risk of heart attack, stroke, atrial fibrillation, heart failure, peripheral artery disease, chronic kidney disease and cardiac death. Although periodontal disease clearly contributes to chronic inflammation that is associated with ASCVD, a cause-and-effect relationship has not been confirmed.
• There is also no direct evidence that periodontal treatment will help prevent cardiovascular disease. However, treatments that reduce the lifetime exposure to inflammation appear to be beneficial to reducing the risk of developing ASCVD. The treatment and control of periodontal disease and associated inflammation may contribute to the prevention and improved management of ASCVD.
• People with one or more cardiovascular disease risk factors are considered to be at higher risk and may benefit from regular dental screenings and targeted periodontal care to address chronic inflammation. Previous studies have found that more frequent tooth brushing is associated with lower 10-year ASCVD risk (13.7% for once-daily or less brushing vs. 7.35% for brushing three or more times per day) and reduced inflammatory markers.
• More research, including long-term studies and randomized controlled trials, is needed to determine whether periodontal treatment can impact ASCVD progression and outcomes.
• In addition, the role of socioeconomic status, access to dental care and other social factors that adversely affect health should be explored to develop targeted prevention and treatment strategies that can help reduce the prevalence and adverse outcomes of periodontal disease and ASCVD.

This scientific statement was prepared by the volunteer writing group on behalf of the Cardiovascular Disease Prevention Committee of the American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young; the Council on Clinical Cardiology; the Stroke Council; the Council on Basic Cardiovascular Sciences; and the Council on Cardiovascular and Stroke Nursing. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association’s official clinical practice recommendations.

Co-authors are Vice Chair Abbas H. Zaidi, M.D., M.S.; Ann F. Bolger, M.D., FAHA; Oscar H. Del Brutto, M.D.; Rashmi Hegde, B.D.S., M.S.; Lauren L. Patton, D.D.S.; Jamie Rausch, Ph.D., R.N.; and Justin P. Zachariah, M.D., Ph.D., FAHA. Authors’ disclosures are listed in the manuscript.

When it comes to sleep, traditional advice has focused on the number of hours a person sleeps. But for older adults, the quality of sleep may affect cognitive performance the following day regardless of their quantity of sleep, according to a new study by researchers from the Penn State College of Health and Human Development and Albert Einstein College of Medicine, Bronx, New York.

In a study published in Sleep Health, the researchers found that the quality of a night of sleep — rather than the length of the night of sleep — predicted how quickly older adults processed information the next day. The researchers evaluated sleep quality based on how much time someone was awake between when they first went to sleep and when they rose in the morning.

“Anyone who has stayed up too late knows that sleep can affect your cognition the next day,” said Orfeu Buxton, professor of biobehavioral health at Penn State and lead author of the study. “In this study, we wanted to identify which aspects of sleep health impact daily cognitive functioning so that people know how to improve their sleep. When it comes to ‘getting a good night’s sleep,’ it would appear that quality matters in the short term for older adults.”

Few studies have examined how poor sleep impacts cognitive functioning the following day, according to Carol Derby, professor of neurology and epidemiology & population health, Louis and Gertrude Feil Faculty Scholar in Neurology at Albert Einstein College of Medicine and senior author of the study.

“Understanding the nuances of how sleep impacts older adults’ cognition and their ability to perform daily activities may indicate which individuals are at risk for later cognitive impairment, such as Alzheimer’s disease,” Derby said.

Measuring sleep and cognitive performance

The study analyzed data from 261 participants who were part of the Einstein Aging Study, a multiyear study of aging and cognitive health. Participants — all over the age of 70 — lived in the community in Bronx County, New York.

For 16 days, participants wore devices similar to Fitbits or smart watches that tracked their sleep. They also completed cognitive assessment “games” six times a day on a smartphone — when they woke up, before they went to bed and four randomly selected times throughout the day. The games, which took roughly four minutes to complete each time, measured different aspects of cognitive performance including visual working memory, visuospatial memory and processing speed. At the study’s conclusion, the researchers had collected a total of 20,532 cognitive assessments from the participants.

On average, participants slept 7.2 hours each night and spent just over one hour awake during a given night of sleep. Additionally, participants took an average of 0.4 naps each day, which is two naps every five days.

When the researchers analyzed each participant’s day-to-day cognitive performance, they found that when an individual was awake for 30 minutes longer during the night than their average amount, their processing speed was slower than usual the next day. Napping the previous day, bedtime and quantity of sleep showed no effect on processing speed or any other aspects of cognitive performance.

When the researchers compared performance on cognitive tests not just to participants’ own performance but across participants in the entire study sample, they found that older adults who, on average, spent more time awake during their night’s sleep performed worse on three of the four cognitive tests. In addition to slower processing speed, participants with more wake time after falling asleep performed worse on two tests of visual working memory.

“Repeatedly waking after you’ve fallen asleep for the night diminishes the overall quality of your sleep,” said Buxton, associate director of both the Penn State Clinical and Translational Science Institute and the Penn State Social Science Research Institute and an investigator in the Penn State Center for Healthy Aging. “We examined multiple aspects of sleep, and quality is the only one that made a day-to-day difference in cognitive performance.”

What should older people do if they have sleep problems?

Nearly half of older adults report some type of sleep disruption. Over time, sleep problems are associated with higher rates of cognitive decline and Alzheimer’s disease, according to the researchers.

“My number one piece of advice is not to worry about sleep problems,” Buxton said. “Worrying only creates stress that can disrupt sleep further. This does not mean that people should ignore sleep, though. There are research-validated interventions that can help you sleep better.”

To promote healthy sleep, people should go to bed at a consistent time each night, aiming for a similar length of sleep in restful circumstances, Buxton continued.

“When it comes to sleep, no single night matters, just like no single day is critical to your exercise or diet,” Buxton said. “What matters is good habits and establishing restful sleep over time.”

For older adults who have sleep problems, the researchers recommended evaluating their sleep environment — including avoiding screens before bed and sleeping in dark, quiet conditions at a consistent time.

If problems persist, the researchers encouraged people to talk to their medical providers about cognitive behavioral therapy, which has been proven to be a safe and effective way to address sleep-related issues. In contrast, the researchers said that medication is not a good solution for many older adults because sleep medication can increase the risk of falling.

Sleep health and Alzheimer’s disease

Ultimately, the goal of this research is to support healthy cognitive aging, the researchers said, particularly factors that could prevent or delay the onset of Alzheimer’s disease and related dementias. While there is extensive research evidence linking sleep and dementia, it is not yet clear whether poor sleep is a risk factor or a consequence of Alzheimer’s disease.

“The work demonstrating the day-to-day impact of sleep quality on cognition among individuals who do not have dementia suggests that disrupted sleep may have an early impact on cognitive health as we age,” Derby said. “This finding suggests that improving sleep quality may help delay later onset of dementia.”

Other contributors to this research included Jonathan Hakun of the Penn State Department of Neurology; Martin J. Sliwinski of the Penn State Department of Human Development and Family Studies and Center for Healthy Aging; Qi Gao of Albert Einstein College of Medicine’s Department of Epidemiology & Population Health; Cuiling Wang of Albert Einstein College of Medicine’s Department of Neurology; Linying Ji of the Montana State University Department of Psychology; Alyssa Gamaldo of the Clemson University Department of Psychology; and Suzanne Bertisch of the Department of Medicine at Brigham and Women’s Hospital and Harvard Medical School.

Women with severe coronary heart disease causing narrowing or blockages in the arteries may derive greater long-term benefits from coronary artery bypass grafting compared with percutaneous coronary intervention, also known as stenting, according to a study by Weill Cornell Medicine investigators.

Bypass surgery uses a blood vessel from another part of the body to reroute blood flow around a narrowed or blocked artery. Stenting is a minimally invasive procedure that uses a catheter to thread a tubelike stent through a blood vessel in the wrist or groin to the heart to open a fully or partially blocked artery.

 The study, published in the European Heart Journal, adds much-needed evidence to guide decisions for women with heart disease—the leading cause of death among women. Historically, women have made up just 20% to 25% of large, prospective clinical trials comparing bypass surgery and stenting, making it hard to draw conclusions about their outcomes.

“If you are a man, and you need coronary revascularization, you will receive what we call evidence-based treatment, because there is strong evidence to guide your treatment decision,” said senior author Dr. Mario Gaudino, the Stephen and Suzanne Weiss Professor in Cardiothoracic Surgery II at Weill Cornell Medicine and a cardiothoracic surgeon at NewYork-Presbyterian/Weill Cornell Medical Center. “If you are a woman, that’s not the case. We don’t have data, and so we use the data generated in men. However, we all know that women are not small men.”

Heart disease in women has many distinct characteristics. Women tend to develop coronary artery disease later in life and present with different symptoms than men, which often leads to delayed diagnoses. Women also have smaller, more vasoreactive coronary arteries, and more coronary microvascular disease compared with men.

Dr. Gaudino and his team partnered with University of Toronto investigators to analyze outcomes in all women in Ontario, Canada younger than 80 years of age who had extensive high-risk artery blockages and underwent stenting or bypass surgery between 2012 and 2021. A subset of 4,066 women were matched by their characteristics to emulate a randomized clinical trial. The dataset included, on average, five years of follow-up data for each woman.

“We were very fortunate to have access to this unique dataset,” said lead author Dr. Kevin An, a clinical fellow in cardiothoracic transplantation and mechanical circulatory support at NewYork-Presbyterian/Columbia University Irving Medical Center, who conducted this research while a research fellow in cardiothoracic surgery at Weill Cornell Medicine. “It allowed us to look at a large number of women with severe coronary artery disease in a real-world setting and follow their long-term outcomes.”  

They found that about 36% of the women who underwent stenting had a major cardiovascular event, such as a heart attack, stroke, need for repeat coronary revascularization, or were readmitted to the hospital for a heart condition or stroke. By comparison, only 22% of the women who underwent bypass surgery had such an event. Women who underwent stenting also had about a 30% higher risk of dying from any cause during the entire follow-up period than women who underwent bypass. During the first six months after the procedures, however, death risks were similar between the two groups.

“Over the long term, bypass surgery seems to be more protective compared to stenting,” said Dr. An. There was, however, one trade-off: women who underwent stenting had a slightly lower stroke risk than women who underwent bypass surgery.

“Currently, women are about half as likely to undergo bypass surgery as men,” said Dr. An. “More definitive data are needed to change practice guidelines,” said Dr. Gaudino. He and his team are conducting a large prospective clinical trial comparing the two interventions in women with severe coronary artery disease to fill that evidence gap.

“For now, treatment decisions should remain individualized,” said Dr. An. “Although our study suggests that bypass surgery may offer more long-term protection compared to stents, anatomical considerations, individual surgical risk, and patient preferences remain critical.”