Successfully addressing this question would no double reveal novel mechanisms and ways of monitoring treatment responses of cardiovascular disease, ultimately leading to novel drug targets, valuable biomarkers and extended new directions of basic research as well.

Tools of studying these cells are mostly available. Both adult cardiomyocytes and endothelial cells from the heart can be isolated and cultured, although cardiomyotyes need to used within 24 hrs and cannot be passaged. However successful preparation of these cells from WT and transgenic animals would permit co-culture experiments and mechanistic studies. These cells can also be studied using in-situ techniques either detecting molecular changes/events or dynamic interactions. Potential challenges would side in selective targeting of these cells, for example, either ECs or cardiomyocytes, once a potential therapeutic is in the testing. Nonetheless, PECAM-ab conjugated techniques have been employed to specifically deliver proteins to endothelial cells, so I am confident most of the challenges can be worked out, particularly within a RFA awardees group with frequent exchanges of ideas.

Results of such research should reveal physiological mechanisms of resilience that could be used to develop interventions that would prevent or cure a variety of heart, lung, blood, and sleep diseases.

Advances in omics, clinical testing
, accumulation of large sets of clinical data and samples
, big data tools
, and increased interest from public (normal volunteers) and patients to participate in large scientific experiments make it feasible.
For instance, these may be healthy people carrying genetic mutations strongly associated with HLBS diseases (or causing rare/familial genetic diseases – these might easier to focus on first), but also people who are not hypertensive, hypercholesterolemic, or diabetic in spite of consistently making bad dietary choices, people who did not develop lung conditions in spite of high pollutant exposure, or are otherwise “protected” from other heart, lung, blood and sleep diseases. This reasoning is not very different from that used to identify ApoA Milano, or even PCSK9 or the “longevity genes”. Such information should reveal physiological mechanisms that could be leveraged to develop interventions to prevent or cure HLBS diseases.

Although it is widely speculated that epigenetic control mechanisms play a critical role in disease pathogenesis, few if any studies, particularly in the CV field, have actually determined if and how epigenetic mechanisms result in functional changes in the plethora of cells that contribute to CV disease pathology. Moreover, there is a general lack of methods available to determine how specific epigenetic modifications, including histone modifications or DNA methylation of a given gene locus impacts gene expression and function of that cell. Rather, most studies have been limited to studying the effects of global alterations in chromatin structure, and/or studying global changes in epigenetic modifications average over the tens or hundreds of cell types and phenotypes within a complex tissue.

We must develop approaches to dissect the causal role of specific epigenetic modifications in controlling cell function in health and disease.

There are approaches evolving that enable one to do epigenomic edting in single cells but thus far they have not been done in the CV system, nor in vivo. They are feasible but will take a major investment to be successful.

Keep in mind that epigenetic mechanisms presumably regulate overall change in cell function as a consequence of exposure to disease promoting stimuli. Importantly, this is in response not only to the environmental milieu to which the cell is currently exposed, but an integral of past signals it and its predecessors experienced. Unlocking these control mechanisms will likely greatly advance our understanding of all disease processes, but particularly CV diseases which typically develop over years or decades.

It is entirely possible and actually likely that several diseases manifesting in different organ systems may have shared pathobiological mechanisms. This could be the case of systemic inflammation or abnormal repair, precipitated by interaction with external agents such as pollution or smoking. This would manifest as different diseases affecting different organ systems (as could be the case of COPD and Lung Cancer) using today's taxonomy.
As it stands (taking the COPD Lung Cancer example) each is treated differently and actually strategically and clinically, they are handled as separate entitites. In all reality, if we can identify the diseases that share common pathogenetic mechanism, it is likely that we can develop common biomarker profiles that will detect disease predisposition so that early intervention can be planned.
In addition and equally important, once common co-morbidities can be grouped by pathobiology, plans can be developed by the medical establishment including health authorities to develop common approaches rather than the disjointed separate specialties that today handle each of the different organ systems.
Finally, the potential of aggregation of diseases into common pathobiological fields can reduce health care cost by integrating fields and voiding dispersion of resources.

It is entirely possible to use large throughput data analysis such as system network analysis to determine in a hypothesis free environment, what is the relationship amongst diseases. This analysis, that can be facilitated by the availability of electronic medical records can provide a first glance evidence of commonality amongst certain diseases.
This can be validated in other cohorts and a plan for profiling a representative sample of those cohorts in order to determine their proteomic and metabolomics profile. This will provide insight into the mechanisms responsible for the expression of the diseases and can lead to translational research aimed at identifying the mechanisms for the generation of the syndrome and potential therapeutic targets.
Once proven correct, it will be possible to identify and treat several diseases simultaneously with targeted therapy once appropriate trials have been completed.
The project here presented is already feasible and likely to offer new roads leading to a better taxonomy, identification and treatment of what now represents a puzzle of different pieces poorly interlocked.
Given the magnitude of the population that is and will be even more affected by multiple chronic diseases, this is a field that is ready for prime research efforts.

A substantial evidence base now exists showing that depression is associated with a two-fold increased risk of death and recurrent CV events in cardiac patients, leading to a recent AHA scientific statement recommending its elevation to the status of a risk factor for adverse medical outcomes in patients with acute coronary syndrome (Lichtman et al., 2014). Yet there is currently no clinical trial evidence that reducing depression improves cardiac morbidity and mortality. A clinical trial, using new, more effective depression treatment methods, such as collaborative care approaches that combine psychological counseling with medication in stepped-care fashion, is needed to determine whether effective treatment of depression can improve survival and reduce clinical cardiovascular events in cardiac patients.

Newer stepped-care treatments for depression, combining medication and psychotherapy, have recently been developed and found to more effectively reduce depression than earlier treatments. By using these newer treatment methods to substantially lower depression, we can better answer the question as to whether treating the newly acknowledged risk factor of depression in ACS patients can improve clinical outcomes in these patients.

Obesity is a health crisis of epic proportions. About 34% of adults in the US have obesity, up from 31 % in 1999 and about 15% in the years 1960 to 1980. The chronic diseases that result from obesity annually cost over $150 billion in weight-related medical bills. Reduction of obesity improves cardiovascular and other health outcomes, yet what is currently known about obesity is inadequate to combat the global obesity epidemic. A comprehensive understanding about the mechanics of obesity may help in developing more effective preventive and treatment strategies, which in turn will substantially improve cardiovascular and other health measures.

Years of obesity research have revealed the complex nature of this disease and its multi-factorial etiology. While research has firmly established the role of energy balance in weight gain and weight loss, it is important to discover upstream factors that predispose only certain individuals to energy imbalance. This may be addressed by further focusing on newly identified putative contributors of obesity, including but not limited to the impact of sleep deprivation, ambient temperature, age at first pregnancy, intrauterine and intergenerational factors, neuro-endocrine factors, epigenetics, environmental chemicals and endocrine disruptors, gut microbes, infections and the immune system, and social and behavioral factors associated with obesogenic behaviors. These studies may provide mechanistic insight that may also lead to the development of new pharmacological approaches. It is possible that cause-specific prevention or treatment approaches may yield more effective results than generic approaches that do not necessarily consider upstream modulators of energy imbalance, or inter-individual differences.

Large randomized trials would answer the ABO and Rh related critical clinical outcomes question for platelet transfusions in all patients who commonly receive multiple platelet transfusions. This would include most patients with acute hematologic diseases, patients undergoing complex cardiac surgery, solid and stem cell transplant recipients and trauma patients. In addition, modeling the effects of ABO and Rh incompatibility/non-identity in animal models and in vitro would provide data on basic platelet immunobiology.
In vitro and animal model studies that might be relevant include effects of ABO immune complexes on endothelial cell and glycan interactions with other cells of the vasculature and blood. Effects on TLR, interleukin receptors and secreted cytokines are additional considerations.

A randomized trial in patients undergoing induction therapy for acute leukemia and/or allogeneic stem cell transplant would accrue enough patients rapidly to answer this question in, at most, two-three years, given the repeated transfusions of platelets to such patients. A comparison of current practice, or intentionally employing ABO/Rh major mismatched platelets (no risk of hemolysis) as the control arm, versus only ABO/Rh identical platelets in the experimental arm is feasible and ethical. Outcomes such as bleeding, time to engraftment and survival (100 day and long term) are important and scientifically of interest. Companion scientific mechanism studies of effects on inflammation, immunity (adaptive and innate) and hemostasis and thrombosis would be feasible in vitro, in animal models and in the patients in the clinical trial. A similar trial would be informative in patients undergoing complex adult or pediatric cardiac surgery (e.g., combined valve/CABG, LVAD insertion, single ventricle physiology operations) or adult/pediatric ECMO settings.
4. References

1. Carr R, et al. Br J Haematol 1990;75:408-13.
2. Heal JM, et al. Ann Hematol 1993;66:309.
3. Heal JM, et al. EurJHaematol 1993;50:110-7.
4. Blumberg N, et al. Transfusion 2001;41:790-3.
5. Shanwell A, et al. Vox Sanguinis 2009;96:316-23.
6. Inaba K, et al. Arch Surg 2010;145:899-906. 

Delaying the onset of injury to vasculature in Type 2 diabetics would have a major impact on quality of life for the diabetic and costs to the healthcare system. Dialysis and related costs are around $200,000/yr and interfere with life and ability to work, leg ulcers are often chronic and in many cases result in amputation.

This study could be performed in the clinical setting or could be completed with chart review to determine diabetics on insulin on insulin and review outcomes. If access to charts for patients continuously treated for five years or longer were available, this study could be done in a shorter timeframe and at less cost. A long term and costly alternative would be to begin a clinical trial. Medical claims data may be an alternative, but it would be important to identify onset of diabetes and treatment for a minimum of five years.

AHA/ACC guidelines subsequent to the NHLBI ATPIII all provide diet-related recommendations for improving public health that, if followed, could offer tremendous benefits in reduced disability, death and health care costs. However, imperative to the implementation of these life-saving recommendations, is an informed and educated provider base that is skilled in: assessment of patients’ diets and eating behaviors, evaluation of possible risk factor contributors and initiation of diet counseling or referral to a qualified nutritionist.

Nowhere is the opportunity greater to assess, evaluate and offer guidance towards improvement of key diet behaviors than in primary care. Patients perceive physicians as credible, respected sources of nutrition counseling. Physician endorsement of diet and lifestyle change favorably influences patient adherence. Research to evaluate patient-centered medical education and training programs is needed to evaluate and compare patient perception, health impact and health outcomes of these translational nutrition efforts. Ultimately, the goal is to further calculate and quantify the economic and personal benefits that accompany these strategies in order to implement transformed medical education aimed at preventive strategies.

This is a major challenge due to current medical training focused on diagnosis and treatment rather than prevention. Research is needed to demonstrate cost/benefit of transformative education and training that shifts the focus from treatment to prevention. Successful outcomes can provide preliminary evidence needed to promote a paradigm shift across -medical schools and allied health professions with the ultimate goal of - improving medical practice and quality of life. Evidence is needed that documents patient-centered impact resulting from this training and actual practice. Proposed is a comprehensive, team science approach to testing the results of nutrition and lifestyle medicine in primary care and the biomedical, behavioral and economic impact derived from it.
This represents an ambitious task requiring an academic medical center environment that not only has the educational aspect in place but also the capacity to provide the translational effort at the bedside and in outpatient settings to allow measurement of results. It requires leadership in multiple arenas and coordination between education and clinical application that are crucial to successful implementation. It further requires leadership and expertise in big data, economics, biostatistics and the accompanying technology required to
assess, analyze and report all of the aspects and components inherent in a project of this magnitude.

The significance of the behavioral and cardiovascular findings in children as they relate to health during adulthood is unknown. It remains to be defined whether the behavioral and cardiovascular abnormalities observed in children with sleep apnea are a reflection of structural and functional brain abnormalities, which might persist into adulthood and predispose to health problems at an older age.
A fundamental question that deserve investigation whether brain maturation in children with sleep apnea and sleep deprivation deviate from normal trajectory and whether brain plasticity can restore normal structure and function.
Such knowledge on brain maturation and plasticity in children with sleep disorders could lead to the identification of brain biomarkers that might signal risk for future mood and behavioral disorders and or cardiovascular diseases. The new knowledge will also identify sensitive period(s) during child development for interventions.

In the last decade, the application of new technologies of fMRI and diffusion MRI have permitted the study of the evolving brain connectome across all stages of development and created new potentials to inform our etiologic understanding of many pediatric and adult diseases.
We now can for the first time examine the brain developmental trajectories in children with chronic medical conditions including sleep disorders and compare the findings to normative data.

As summarized following the Working Group meeting,compared with the situation for cardiovascular risk factor management, there is little well-founded evidence regarding the efficacy, safety, and clinical impact of dietary modifications for patients with various HF phenotypes. The importance of diet and nutrition to promote health and prevent or control disease is well established. Research on obesity, hypertension and cardiovascular disease have contributed to the development of nutritional guidelines to prevent these disease in the general population but efforts to determine nutritional needs for the patient with HF lack high caliber evidence regarding safety, efficacy, and clinical impact of dietary modifications. The stronger evidence and focus on disease prevention and health promotion with diet modifications like DASH cannot be easily applied or extrapolated for disease management, especially HF, because of critical knowledge gaps and potential harm. Research on HF has more recently identified and differentiated medical treatment and interventions appropriate for HF with or without preserved ejection fractions. This only adds to the questions surrounding diet and nutritional approaches to help reduce and prevent HF readmissions.

Chronic HF often presents as a multisystem disease with important co-morbidities such as anemia, insulin resistance or diabetes, autonomic dysregulation, and impaired renal function. Intestinal dysfunction with impaired motility and circulation and disturbed intestinal barrier and flora may lead to a chronic inflammatory state and nutrient malabsorption. In advanced cases, catabolic/anabolic imbalance is associated with cardiac cachexia, a difficult to treat condition which itself carries a poor prognosis. Furthermore, psychosocial symptoms associated with HF, including depression and impaired cognition, can contribute to poor self-care and lack of adherence to recommended dietary, physical activity, and medication regimens. Nutritional status concerns for patients with HF increase with disease severity. Salt restriction is now controversial and clinicians give little attention to diet as a potential intervention to improve outcomes. Proposed recommendations:
1.Determine the correct sodium threshold; ranges of sodium and fluid intake, and the safety for sub-groups including HFPEF, HFREF, and cardiorenal syndrome. 2.Generate new knowledge which identifies therapeutic targets and understand the role of the gut microbiome on gastrointestinal malabsorption, inflammation, and protein balance in HF.
3.Apply innovative study designs to reduce evidence gaps 4.Develop technologies to facilitate nutrition research and address weight and multiple risk factors should be addressed.

Understanding the mechanism of how myocardium becomes irreversibly injured will provide clarity for therapeutic intervention.

Advances in proteomics and databases of post-translational modifications may support the feasibility of discoveries in this area.
This information is key for designing novel therapeutic strategies for acute myocardial ischemic injury. This understanding will define the critical timing, location, and distribution of modulators, and amplitude required for activation of components involved in protective pathways.

Previous studies have focused on high cholesterol as a risk factor for cardiovascular disease (CVD). Recent epidemiologic and genetic studies with apoCIII mutation, for example, have identified significant contribution of high triglycerides (TGs) to the development of atherosclerotic CVD. In particular, the epidemics of obesity, even from young age, in the US and worldwide have caused significant increases in the prevalence of hypertriglyceridemia, which has become a serious health problem. However, how hypertriglyceridemia increases risk for atherosclerotic CVD remains largely unknown. Further translational and basic studies would be needed to examine how TG-rich lipoproteins and cholesterol-rich lipoproteins cooperate to increase the risk for CVD. Basic research would need to be conducted at integrative, cellular and molecular levels including examining how TGs are metabolized and how TG-rich lipoproteins, along with cholesterol-rich lipoproteins, cause atherosclerosis. These studies would guide clinical approach on TG- versus cholesterol-lowering therapy for prevention and treatment of atherosclerotic CVD.

The challenges include combining large clinical studies and basic research. Clinical studies includes confirming high TGs as an independent risk for atherosclerotic CVD, developing novel TG-lowering therapy and examining whether these novel TG-lowering therapy, with apoCIII as a target for example, would be beneficial in prevention and treatment of CVD. It is also important to examine effects of novel TG-lowering therapy on adiposity, adipose tissue function and risk of diabetes. Basic science needs to elucidate how TGs are metabolized in vivo, causing hypertriglyceridemia, and how hypertriglyceridemia increases risk for atherosclerotic CVD, and identify novel pathways for these pathophysiological processes, which would provide novel strategies for development of new therapy for CVD. Collaborative approach with great financial support will make all these feasible.

This will require a combination of informatics, state of the art imaging, and state of the art genetics and omics profiling with integration with the electronic health record.