Race-Related Differences in Left Ventricular Structural and Functional Remodeling in Response to Increased Afterload: The ARIC Study

Distinguishing hypertensive cardiomyopathy from cardiac amyloidosis in hypertensive patients with heart failure: a CMR study with histological confirmation

PURPOSE

Differentiation of the cause of left ventricular hypertrophy (LVH) is challenging in cases with co-existing hypertension. CMR offers assessment of diffuse myocardial abnormalities via T1 mapping with extracellular volume fraction (ECV) and macroscopic fibrosis via late gadolinium enhancement imaging (LGE). The goal of the study was to understand if CMR parameters can differentiate hypertensive cardiomyopathy (HC) from cardiac amyloidosis (CA) in patients with hypertension and heart failure, using endomyocardial biopsy (EMB) as the gold standard.

METHODS

We retrospectively analyzed patients with hypertension, LVH, and heart failure undergoing EMB due to uncertain diagnosis. CMR parameters including cine, LGE characteristics, T1 mapping, and ECV were analyzed.

RESULTS

A total of 34 patients were included (mean age 66.5 ± 10.7 years, 79.4% male). The final EMB-based diagnosis was HC (10, 29%), light chain (AL) CA (7, 21%), and transthyretin (ATTR) CA (17, 50%). There was a significant difference in subendocardial LGE (p = 0.03) and number of AHA segments with subendocardial LGE (p = 0.005). The subendocardial LGE pattern was most common in AL-CA (85.7%) and African American with HC (80%). ECV elevation (≥ 29%) was present in all patients with CA (AL-CA: 57.6 ± 5.2%, ATTR-CA: 59.1 ± 15.3%) and HC (37.3 ± 4.5%).

CONCLUSIONS

Extensive subendocardial LGE pattern is not pathognomonic for CA but might also be present in African American patients with longstanding or poorly controlled HTN. The ECV elevation in HC with HF might be more significant than previously reported with an overlap of ECV values in HC and CA, particularly in younger African American patients.

Clinical, Echocardiographic, and Longitudinal Characteristics Associated With Heart Failure With Improved Ejection Fraction

Heart failure with improved ejection fraction (HFimpEF) has better outcomes than HF with reduced EF (HFrEF). However, factors contributing to HFimpEF remain unclear. This study aimed to evaluate clinical and longitudinal characteristics associated with subsequent HFimpEF. This was a single-center retrospective HFrEF cohort study. Data were collected from 2014 to 2022. Patients with HFrEF were identified using International Classification of Diseases codes, echocardiographic data, and natriuretic peptide levels. The main end points were HFimpEF (defined as EF >40% at ≥3 months with ≥10% increase) and mortality. Cox proportional hazards and mixed effects models were used for analyses. The study included 1,307 patients with HFrEF with a median follow-up of 16.3 months (interquartile range 8.0 to 30.6). The median age was 65 years; 68% were male whereas 57% were White. On follow-up, 38.7% (n = 506) developed HFimpEF, whereas 61.3% (n = 801) had persistent HFrEF. A multivariate Cox regression model identified gender, race, co-morbidities, echocardiographic, and natriuretic peptide as significant covariates of HFimpEF (p <0.05). The HFimpEF group had better survival compared with the persistent HFrEF group (p <0.001). Echocardiographic and laboratory trajectories differed between groups. In this HFrEF cohort, 38.7% transitioned to HFimpEF and approximately 50% met the definition within the first 12 months. In a HFimpEF model, gender, co-morbidities, echocardiographic parameters, and natriuretic peptide were associated with subsequent HFimpEF. The model has the potential to identify patients at risk of subsequent persistent or improved HFrEF, thus informing the design and implementation of targeted quality-of-care improvement interventions.

Health equity in heart failure

The treatment of heart failure (HF) with reduced ejection fraction (HFrEF) has substantially developed over the past decades. More than ever before, the application of appropriate evidence-based medical therapy for HFrEF is associated with remarkable improvements in survival, noteworthy increases in quality of life, and a marked reduction in symptomatic HF sufficient to warrant hospitalization. These enhanced clinical outcomes are driven by the "four pillars" of HF therapy: 1) evidence-based beta blockers, 2) Renin-angiotensin-aldosterone system inhibitors (angiotensin-converting enzyme inhibitors /angiotensin II receptor blockers or angiotensin receptor-neprilysin inhibitors, 3) mineralocorticoid receptor antagonists, and most recently, 4) sodium-glucose cotransporter-2 inhibitors. Despite robust evidence from well-conducted randomized clinical trials, guideline-directed medical therapies with established cardiovascular benefits remain significantly underutilized in clinical practice, particularly among under-represented minority populations. This phenomenon has led to class 1 level recommendations from the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America Guidelines to address HF disparities among vulnerable populations as follows. In this article, we highlight the difference between health equality and health equity and discuss the need to address equity in the treatment of heart failure, ensuring that the impressive progress made in the treatment of HFrEF is equally beneficial to all individuals. We discuss strategies to reduce and ultimately eliminate disparities in the determinants of health that particularly affect marginalized groups, including the socioeconomic determinants and racism as a threat to public health. Finally, we discuss and propose a combination of the four pillars of ethics with the four pillars of GDMT to optimize and personalize treatment of all patients with HFrEF, to achieve true equity in the treatment of HF.

Clinical, Echocardiographic, and Longitudinal Characteristics Associated with Heart Failure with Improved Ejection Fraction

Background

Heart failure (HF) with improved ejection fraction (HFimpEF) has better outcomes than HF with reduced ejection fraction (HFrEF). However, factors contributing to HFimpEF remain unclear. This study aimed to evaluate clinical and longitudinal characteristics associated with subsequent HFimpEF.

Methods

This was a single-center retrospective HFrEF cohort study. Data were collected from 2014 to 2022. Patients with HFrEF were identified using ICD codes, echocardiographic data, and natriuretic peptide levels. The main endpoints were HFimpEF (defined as ejection fraction >40% at ≥3 months with ≥10% increase) and mortality. Cox proportional hazards and mixed effects models were used for analyses.

Results

The study included 1307 HFrEF patients with a median follow-up of 16.3 months (IQR 8.0-30.6). The median age was 65 years; 68% were male while 57% were white. On follow-up, 39% (n=506) developed HFimpEF, while 61% (n=801) had persistent HFrEF. A multivariate Cox regression model identified sex, race comorbidities, echocardiographic, and natriuretic peptide as significant covariates of HFimpEF ( p <0.05). The HFimpEF group had better survival compared to the persistent HFrEF group ( p <0.001). Echocardiographic and laboratory trajectories differed between groups.

Conclusion

In this HFrEF cohort, 39% transitioned to HFimpEF and approximately 50% met the definition within the first 12 months. In a HFimpEF model, sex, comorbidities, echocardiographic parameters, and natriuretic peptide were associated with subsequent HFimpEF. The model has the potential to identify patients at risk of subsequent persistent or improved HFrEF, thus informing the design and implementation of targeted quality-of-care improvement interventions.

A Left ventricle remodeling in patients with bicuspid aortic valve

PURPOSE

We assessed the impact of bicuspid aortic valve (BAV), aortic stenosis (AS), and regurgitation (AR) on the metrics of left ventricular (LV) remodeling, as measured by electrocardiogram (ECG), transthoracic echocardiography (TTE), and cardiac magnetic resonance (CMR).

METHODS

This retrospective CMR study included 11 patients with both AS and AR (BAV-ASR), 30 with AS (BAV-AS), 28 with AR (BAV-AR), 47 with neither AS nor AR (BAV-no_AS/AR), and 40 with trileaflet aortic valve (TAV-no_AS/AR). CMR analysis included the LV end-diastolic volume index (LVEDVi), mass index (LVMi), and extracellular volume fraction (ECV). The Sokolow-Lyon and Cornell products by ECG and TTE-derived E/e' were measured.

RESULTS

There were no differences in the ECG, TTE, and CMR parameters between BAV-no_AS/AR and TAV-no_AS/AR. However, the presence of aortic valve dysfunction resulted in an elevated Sokolow-Lyon product for BAV-ASR (p = 0.017) and BAV-AR (p = 0.001), as well as increased Cornell product (p = 0.04) and E/e' (p < 0.001) for BAV-AS compared with BAV-no_AS/AR. LVEDVi and LVMi were elevated in patients with BAV-ASR and BAV-AR compared with those with BAV-no_AS/AR (LVEDVi: 101 ± 29 ml/m² and 112 ± 32 ml/m² vs. 74 ± 15 ml/m², p = 0.005 and p < 0.001, LVMi: 75 ± 7 g/m² and 64 ± 14 g/m² vs. 47 ± 9 g/m², respectively; p < 0.001). There was no difference in ECV between the BAV and TAV-no_AS/AR subgroups.

CONCLUSION

Normally functioning BAV did not result in LV remodeling. However, concomitant AV dysfunction was associated with statistically significant morphological remodeling.

Echocardiography-Based Cardiac Structure Parameters for the Long-term Risk of End-Stage Kidney Disease in Black Individuals: The Atherosclerosis Risk in Communities Study

OBJECTIVE

To assess whether echocardiographic parameters of left ventricular (LV) structure and function relate to the long-term risk of incident end-stage kidney disease (ESKD).

PATIENTS AND METHODS

We conducted a prospective cohort study analyzing 2137 Black participants from the Jackson site of the Atherosclerosis Risk in Communities Study from January 1, 1993, through July 31, 2017. Echocardiographic parameters of LV structure and function were obtained from 1993 to 1995. The primary outcome incident ESKD was identified through the linkage to the United States Renal Data System. Cox proportional hazards models were used to estimate the hazard ratios (HRs) according to each echocardiographic parameter.

RESULTS

There were 117 incident ESKD cases during a median follow-up of 22.2 (interquartile range, 15.0-23.3) years. Multivariable Cox models revealed that a higher LV mass index was significantly associated with the risk of ESKD (HR, 2.38; 95% CI, 1.21 to 4.68 for highest vs lowest quartile, P = 0.012). The HRs were significant and even higher for LV posterior wall thickness, with slightly higher HRs when their measures in end-systole (HR for highest vs lowest quartile, 4.38; 95% CI, 1.94 to 9.92, P < 0.001) vs end-diastole (HR, 3.50; 95% CI, 1.53 to 8.01, P = 0.003) were used. The associations were not significant for LV function parameters.

CONCLUSION

In Black individuals residing in the community, echocardiographic parameters of LV structure, including LV wall thickness, were robustly associated with the risk of subsequently incident ESKD. These results have potential implications for novel prevention and management strategies for persons with abnormal LV structure.

Subclinical Risk Factors for Heart Failure With Preserved and Reduced Ejection Fraction Among Black Adults

Importance

Sparse data exist regarding the contributions of subclinical impairments in cardiovascular and noncardiovascular function to incident heart failure (HF) with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF) among Black US residents, limiting understanding of the etiology of HF subtypes.

Objectives

To identify subclinical cardiovascular and noncardiovascular risk factors associated with HFrEF and HFpEF in Black US residents.

Design, Setting, and Participants

This cohort study used cross-sectional and time-to-event analysis with data from the community-based Jackson Heart Study (JHS), a longitudinal cohort study with baseline data collected from 2000 to 2004 (visit 1) and 10-year follow-up for incident HF. Black US residents from the Jackson, Mississippi, metropolitan area enrolled in JHS; those with prevalent HF, with moderate or greater aortic or mitral valve diseases on visit 1, who died before 2005, and who had missing HF status on follow-up were excluded. The analysis included 4361 participants and was performed between June 2020 to August 2021.

Exposures

Quantitative measures of cardiovascular (left ventricular mass index [LVMI], left ventricular ejection fraction [LVEF], left atrial [LA] diameter, and pulse pressure) and noncardiovascular (percent predicted forced expiration volume in 1 second [FEV1 (percent predicted)], estimated glomerular filtration rate (eGFR), waist circumference, and hemoglobin A1c [HbA1c] level) organ function.

Main Outcomes and Measures

Incident HF, HFrEF, and HFpEF over 10-year follow-up.

Results

The 4361 participants had a mean (SD) age of 54 (13); 2776 (64%) were women; and there were 163 HFpEF and 146 HFrEF events. In multivariable models incorporating measures reflecting each organ system, factors associated with incident HFpEF included greater LA diameter (hazard ratio [HR], 1.23; 95% CI, 1.03-1.47; P = .02), higher pulse pressure (HR, 1.23; 95% CI, 1.05-1.44; P = .009), lower FEV1 (percent predicted) (HR, 1.22; 95% CI, 1.04-1.43; P = .02), lower eGFR (HR, 1.43; 95% CI, 1.19-1.72; P < .001), higher HbA1c level (HR, 1.25; 95% CI, 1.07-1.45; P = .005), and higher waist circumference (HR, 1.41; 95% CI, 1.18-1.69; P < .001). Factors associated with incident HFrEF included greater LVMI (HR, 1.25; 1.07-1.46; P = .005), lower LVEF (HR, 1.65; 95% CI, 1.42-1.91; P < .001), lower FEV1 (percent predicted) (HR, 1.19; 95% CI, 1.00-1.42; P = .047), and lower eGFR (HR, 1.27; 95% CI, 1.04-1.55; P = .02).

Conclusions and Relevance

In this community-based cohort study of Black US residents, subclinical impairments in cardiovascular and noncardiovascular organ function were differentially associated with risk of incident HFpEF and HFrEF.

Racial Differences in Val122Ile-Associated Transthyretin Cardiac Amyloidosis

BACKGROUND

The valine-to-isoleucine substitution (Val122Ile) is the most common variant of transthyretin (TTR) amyloidosis in the United States, affecting primarily individuals of African descent. This variant has been identified recently in a cluster of white individuals in Italy.

METHODS AND RESULTS

Clinical phenotype and chamber performance of Black and white individuals with Val122Ile TTR cardiac amyloidosis (ATTR-CA) were compared. Compared to white patients (n = 17), Black individuals (n = 53) had lower systolic blood pressures (110 vs 131 mmHg, <0.001), reduced pulse pressures (41 vs 58 mmHg; P < 0.001), and impaired renal function (eGFR 46 vs 67 mL/min/1.73m²; P < 0.001) at presentation. Systolic properties and arterial elastance were similar. Black patients had end-diastolic pressure-volume relationships that were shifted upward and leftward relative to those of white patients, indicating reduced left ventricular chamber capacitance. Pressure-volume area at a left ventricular end-diastolic pressure of 30 mmHg was lower in Black than in white individuals (8055 mmHg/mL vs 11,538 mmHg/mL; P = 0.008).

CONCLUSION

Despite presenting at ages similar to those of white patients, Black individuals with Val122Ile-associated ATTR-CA had a greater degree of cardiac chamber dysfunction at the time of diagnosis due to impaired ventricular capacitance. Whether these differences are attributable to amyloidosis or other cardiovascular disease requires further study.

Assessing race and ethnicity differences in outcomes based on GDMT and target NT-proBNP in patients with heart failure with reduced ejection fraction: An analysis of the GUIDE-IT study

BACKGROUND

The GUIDE-IT trial was, a multicenter, randomized, parallel group, unblinded study that randomized patients to having heart failure therapy titrated to achieve an NT-proBNP <1000 pg/mL or to usual clinical care.

METHODS AND RESULTS

We performed pre-specified subgroup analysis to look for the race and ethnicity-based differences in clinical outcomes of patients who were able to achieve GDMT or target NT-proBNP concentration of ≤1000 pg/mL at 90 days of follow-up. There were 894 patients enrolled in GUIDE-IT study. Of these, 733 participants had available data on 90-day guideline directed triple therapy and 616 on NT-proBNP. 35% of the patients were Black and 6% were Hispanic. Black patients were younger, had more comorbidities, lower EF, and higher NYHA class compared with non-Black. Adjusting for 90-day NT-proBNP and important baseline covariates, Black patients were at a higher risk than non-Black patients for HF hospitalization [HR, 2.19; 95% CI, 1.51-3.17; p < 0.0001], but at a similar risk for mortality [HR, 0.85.; 95% CI, 0.44-1.66; p = 0.64]. Similar results were seen adjusting for 90-day GDMT [HF hospitalization: Black vs non-Black, HR: 1.97; 1.41-2.77, P < 0.0001; mortality: HR: 0.70; 0.39-1.26, p = 0.23]. There were no significant differences between Hispanic and non-Hispanic patients with respect to heart failure hospitalization, cardiovascular or all-cause mortality. Over the study period, Black and Hispanic patients experienced smaller changes in physical function and quality of life as measured by the Kansas City Cardiomyopathy Questionnaire overall score.

CONCLUSION

Compared to non-Black patients, Black patients in GUIDE-IT study had a higher risk of heart failure hospitalization, but a comparable risk of mortality, despite improved use of GDMT and achievement of similar biomarker targets.

Racial Differences in XO (Xanthine Oxidase) and Mitochondrial DNA Damage-Associated Molecular Patterns in Resistant Hypertension

BACKGROUND

We previously reported increased plasma XO (xanthine oxidase) activity in patients with resistant hypertension. Increased XO can cause mitochondrial DNA damage and promote release of fragments called mitochondrial DNA damage-associated molecular patterns (mtDNA DAMPs). Here, we report racial differences in XO activity and mtDNA DAMPs in Black and White adults with resistant hypertension.

METHODS

This retrospective study includes 91 resistant hypertension patients (44% Black, 47% female) with blood pressure >140/90 mm Hg on ≥4 medications and 37 normotensive controls (30% Black, 54% female) with plasma XO activity, mtDNA DAMPs, and magnetic resonance imaging of left ventricular morphology and function.

RESULTS

Black-resistant hypertension patients were younger (mean age 52±10 versus 59±10 years; P=0.001), with higher XO activity and left ventricular wall thickness, and worse diastolic dysfunction than White resistant hypertension patients. Urinary sodium excretion (mg/24 hour per kg) was positively related to left ventricular end-diastolic volume (r=0.527, P=0.001) and left ventricular mass (r=0.394, P=0.02) among Black but not White resistant hypertension patients. Patients with resistant hypertension had increased mtDNA DAMPs versus controls (P<0.001), with Black mtDNA DAMPS greater than Whites (P<0.001). Transmission electron microscopy of skeletal muscle biopsies in resistant hypertension patients demonstrates mitochondria cristae lysis, myofibrillar loss, large lipid droplets, and glycogen accumulation.

CONCLUSIONS

These data warrant a large study to examine the role of XO and mitochondrial mtDNA DAMPs in cardiac remodeling and heart failure in Black adults with resistant hypertension.

Reference values for left ventricular dimensions, systolic and diastolic function: a study from the Amazon Basin of Brazil

Country- and ethnicity-specific reference values for echocardiographic parameters are necessary for decision making. No prior studies have examined reference values in adults from the Amazon Basin of Brazil. We performed echocardiographic examinations in 290 healthy adults (mean age 37 ± 14 years, 40% male) from the Brazilian Amazon. Left ventricular (LV) dimensions and volumes were obtained and indexed to body surface area. We also assessed systolic (LV ejection fraction [LVEF] and global longitudinal strain [GLS]) and diastolic function. LV dimensions and volumes were larger in males compared to females, but after indexation only volumes remained larger (P < 0.001 for all). Parameters of systolic function, were significantly greater in females (LVEF 50 to 68%, GLS - 17 to - 24%) than in males (LVEF 50 to 67%, GLS - 15 to - 23%, P < 0.05). Upper limits of normality for cardiac dimensions (indexed and non-indexed) were markedly higher compared to contemporary guidelines (American Society of Echocardiography) and the Brazilian subgroup in the World Alliance Society of Echocardiography (WASE). Lower limit of normality for LVEF (both sex 50%) and upper limit of normality for the left atrial volume index (LAVI) (male: 31 mL/m2, female: 25 mL/m2) were within normal range but slightly lower compared to guidelines and the WASE study. Other diastolic parameters, including E/A-ratio, E/e' ratio and peak tricuspid regurgitation velocity were compatible with present recommendations. Normal reference ranges of echocardiographic parameters in healthy adults from the Brazilian Amazon Basin may be different compared to international guidelines and data from other regions of Brazil. This applies specifically for LVEF and LAVI.

Posture-Related Differences in Cardiovascular Function Between Young Men and Women: Study of Noninvasive Hemodynamics in Rural Malawi

Background

Cardiovascular risk is higher in men than in women, but little information exists about sex‐related differences in cardiovascular function from low‐income countries. We compared hemodynamics between sexes in rural Malawi in a cohort followed up since their birth.

Methods and Results

Supine, seated, and standing hemodynamics were recorded from 251 women and 168 men (mean age, 21 years; body mass index, 21 kg/m²) using oscillometric brachial waveform analyses (Mobil‐O‐Graph). The results were adjusted for estimated glomerular filtration rate, and plasma potassium, lipids, and glucose. Men had higher brachial and aortic systolic blood pressure and stroke index regardless of posture (P<0.001), and higher upright but similar supine diastolic blood pressure than women. Regardless of posture, heart rate was lower in men (P<0.001), whereas cardiac index did not differ between sexes. Women presented with lower supine and standing systemic vascular resistance index (P<0.001), whereas supine‐to‐standing increase in vascular resistance (P=0.012) and decrease in cardiac index (P=0.010) were higher in women. Supine left cardiac work index was similar in both sexes, whereas standing and seated left cardiac work index was higher in men than in women (P<0.001).

Conclusions

In young Malawian adults, men had higher systolic blood pressure, systemic vascular resistance, and upright cardiac workload, whereas women presented with higher posture‐related changes in systemic vascular resistance and cardiac output. These findings show systematic sex‐related differences in cardiovascular function in a cohort from a low‐income country with high exposure to prenatal and postnatal malnutrition and infectious diseases.

Association between Coronary Artery Disease and Left Ventricle Remodeling Parameters in Hypertensive Patients: A Cross-Sectional Study in a Limited Resource Setting

BACKGROUND: Coronary artery disease (CAD) and hypertension are related with left ventricle (LV) remodeling, however evidence about association between CAD and remodeling in hypertensive patient is still limited, especially in limited resource setting like Indonesia. AIM: Evaluating impact of CAD on LV remodeling within hypertensive patients at tertiary referral hospital, Hasan Sadikin General Hospital Bandung, Indonesia. METHOD: Cross-sectional study involving 120 hypertensive patients who visited cardiology outpatient clinic from September-December 2019 and underwent transthoracic echocardiography examination for any medical indications. LV remodeling parameters, such as mass (LV Mass Index [LVMi]), volume (end-diastolic volume/body surface area [BSA]), and relative wall thickness (RWT), were compared between CAD and non-CAD groups. RESULTS: There were 108 patients to be analyzed, 12 patients were excluded due to technical difficulty (n = 9) and non-cooperative during interview (n = 3). Mean (standard deviation) age of patients was 56.9 (±11.8) years, 50 (46.3%) patients were male, and median (interquartile range) hypertension duration was 3 (±4.40) years. CAD was found in 40 (37.0%) patients. In the adjusted analysis, patients with CAD had average 27.75 g/m2 higher LVMi (95% confined interval [CI] 2.03; 53.47; p = 0.035) and 16.20 ml/m2 higher LV end-diastolic volume/BSA (95% CI 4.14; 28.25; p = 0.009) compared to those without. This was independent of age, duration of hypertension, consumption of antihypertensive therapy, and type-2 diabetes mellitus, but disappeared after heart failure (HF) was included in the study. CAD and non-CAD groups were not different, respectively, to RWT. CONCLUSION: In hypertensive patients, CAD was independently associated with higher LV mass and volume. These associations, however, were largely explained by the presence of HF. CAD did not associate with RWT.

Association between race and maladaptive concentric left ventricular hypertrophy in American-style football athletes

OBJECTIVES

American-style football (ASF) athletes are at risk for the development of concentric left ventricular hypertrophy (C-LVH), an established cardiovascular risk factor in the general population. We sought to address whether black race is associated with acquired C-LVH in collegiate ASF athletes.

METHODS

Collegiate ASF athletes from two National Collegiate Athletic Association Division-I programmes were recruited as freshmen between 2014 and 2019 and analysed over 3 years. Demographics (neighbourhood family income) and repeated clinical characteristics and echocardiography were recorded longitudinally at multiple timepoints. A mixed-modelling approach was performed to evaluate acquired C-LVH in black versus white athletes controlling for playing position (linemen (LM) and non-linemen (NLM)), family income, body weight and blood pressure.

RESULTS

At baseline, black athletes (N=124) were more often NLM (72% vs 54%, p=0.005) and had lower median neighbourhood family income ($54 119 vs $63 146, p=0.006) compared with white athletes (N=125). While both black and white LM demonstrated similar increases in C-LVH over time, among NLM acquired C-LVH was more common in black versus white athletes (postseason year-1: N=14/89 (16%) vs N=2/68 (3%); postseason year-2: N=9/50 (18%) vs N=2/32 (6%); postseason year-3: N=8/33 (24%) vs N=1/13 (8%), p=0.005 change over time). In stratified models, black race was associated with acquired C-LVH in NLM (OR: 3.70, 95% CI 1.12 to 12.21, p=0.03) and LM was associated with acquired C-LVH in white athletes (OR: 3.40, 95% CI 1.03 to 11.27, p=0.048).

CONCLUSIONS

Independent of family income and changes in weight and blood pressure, black race was associated with acquired C-LVH among collegiate ASF NLM and LM was associated with acquired C-LVH in white athletes.

Prognostic Significance of Echocardiographic Measures of Cardiac Remodeling in the Community

PURPOSE OF REVIEW

Echocardiography is a noninvasive tool of choice for evaluating cardiac structure and function in numerous cardiac conditions ranging from congenital heart disease, myocardial diseases, coronary artery disease (CAD), valvulopathies, arrhythmias, and pericardial disorders. We review the prognostic significance of echocardiographic indices of cardiac remodeling in the general population.

RECENT FINDINGS

Recent meta-analyses have confirmed the prognostic significance of echocardiographic measurements (left ventricular mass/hypertrophy, systolic and diastolic dysfunction, left atrial dimensions and function, and strain rate measures) in asymptomatic people in the community for adverse clinical outcomes including CAD, stroke, heart failure, atrial fibrillation, sudden death, and all-cause mortality. The clinical utility of screening echocardiography has been examined comprehensively in hypertensive patients, where it is challenged by measurement variability. Echocardiographic measures predict cardiovascular disease outcomes consistently in multiple community-based epidemiological studies. However, the clinical utility of screening asymptomatic individuals with echocardiography in population-based settings is limited.

Epidemiology of Heart Failure Stages in Middle-Aged Black People in the Community: Prevalence and Prognosis in the Atherosclerosis Risk in Communities Study

Background Black individuals have a higher burden of risk factors for heart failure (HF) and subclinical left ventricular remodeling. Methods and Results We evaluated 1871 Black participants in the Atherosclerosis Risk in Communities Study cohort who attended a routine examination (1993-1996, median age 58 years) when they underwent echocardiography. We estimated the prevalences of 4 HF stages: (1) Stage 0: no risk factors; (2) Stage A: presence of HF risk factors (hypertension, diabetes mellitus, obesity, smoking, dyslipidemia, coronary artery disease without clinical myocardial infarction), no cardiac structural/functional abnormality; (3) Stage B: presence of prior myocardial infarction, systolic dysfunction, left ventricular hypertrophy, regional wall motion abnormality, or left ventricular enlargement; and (4) Stage C/D: prevalent HF. We assessed the incidence of clinical HF, atherosclerotic cardiovascular disease events, and all-cause mortality on follow-up according to HF stage. The prevalence of HF Stages 0, A, B, and C/D were 3.8%, 20.6%, 67.0%, and 8.6%, respectively, at baseline. On follow-up (median 19.0 years), 309 participants developed overt HF, 390 incurred new-onset cardiovascular disease events, and 651 individuals died. Incidence rates per 1000 person-years for overt HF, cardiovascular disease events, and death, respectively, were Stage 0, 2.4, 0.8, and 7.6; Stage A, 7.4, 9.7, and 13.5; Stage B 13.6, 15.9, and 22.0. Stage B HF was associated with a 1.5- to 2-fold increased adjusted risk of HF, cardiovascular disease events and death compared with Stages 0/A. Conclusions In our large community-based sample of Black individuals, we observed a strikingly high prevalence of Stage B HF in middle age that was a marker of high cardiovascular morbidity and mortality.

Prevalence of heart disease in patients with mitochondrial abnormalities on skeletal muscle biopsy

Objective

Mitochondrial DNA mutations are associated with an increased risk of heart disease. Whether an increased prevalence of cardiovascular disease is present in patients presenting with mitochondrial abnormalities on skeletal muscle biopsy remains unknown. This study was designed to determine the prevalence of cardiac conduction disease and structural heart disease in patients presenting with mitochondrial abnormalities on skeletal muscle biopsy.

Methods

This is a retrospective cohort study of 103 patients with mitochondrial abnormalities on skeletal muscle biopsy who were referred for evaluation of muscle weakness at a single tertiary care referral center from 2012 to 2018. Of these patients, 59 (57.3%) had an electrocardiogram available and were evaluated for the presence of conduction disease. An echocardiogram was available in 43 patients (42%) who were evaluated for the presence of structural heart disease. The prevalence of cardiac disease was compared to control cohort populations (Framingham and the Atherosclerosis Risk in Communities, ARIC cohorts).

Results

Mitochondrial abnormalities associated with cardiac conduction disease (defined as QRS duration ≥ 120 msec) were present in 8.9%, versus 2.0% (p < 0.001) in the Framingham population and 2.6% (p = 0.003) in the ARIC cohort. LV systolic dysfunction (LVEF ≤ 50%) was present in 11.6%, versus 3.6% (p < 0.01) in the Framingham and 3% (p < 0.01) in the ARIC populations. Left ventricular hypertrophy was present in 28.6%, versus 13.6% (p < 0.02) in the Framingham and 10.4% (p < 0.001) in the ARIC populations.

Interpretation

Given the increased prevalence of cardiovascular disease, patients with mitochondrial abnormalities on skeletal muscle biopsy should undergo routine cardiac screening with physical exam, electrocardiography, and cardiac imaging.

Contemporary Reevaluation of Race and Ethnicity With Outcomes in Heart Failure

Background

Variation in outcomes by race/ethnicity in adults with heart failure (HF) has been previously observed. Identifying factors contributing to these variations could help target interventions. We evaluated the association of race/ethnicity with HF outcomes and potentially contributing factors within a contemporary HF cohort.

Methods and Results

We identified members of Kaiser Permanente Northern California, a large integrated healthcare delivery system, who were diagnosed with HF between 2012 and 2016 and had at least 1 year of prior continuous membership and left ventricular ejection fraction data. We used Cox regression with time‐dependent covariates to evaluate the association of self‐identified race/ethnicity with HF or all‐cause hospitalization and all‐cause death, with backward selection for potential explanatory variables. Among 34 621 patients with HF, compared with White patients, Black patients had a higher rate of HF hospitalization (adjusted hazard ratio [HR], 1.28; 95% CI, 1.18–1.38) but a lower rate of death (adjusted HR, 0.78; 95% CI, 0.72–0.85). In contrast, Asian/Pacific Islander patients had similar rates of HF hospitalization, but lower rates of all‐cause hospitalization (adjusted HR, 0.89; 95% CI, 0.85–0.93) and death (adjusted HR, 0.75; 95% CI, 0.69–0.80). Hispanic patients also had a lower rate of death (adjusted HR, 0.85; 95% CI, 0.80–0.91). Sensitivity analyses showed that effect sizes for Black patients were larger among patients with reduced ejection fraction.

Conclusions

In a contemporary and diverse population with HF, Black patients experienced a higher rate of HF hospitalization and a lower rate of death compared with White patients. In contrast, selected outcomes for Asian/Pacific Islander and Hispanic patients were more favorable compared with White patients. The observed differences were not explained by measured potentially modifiable factors, including pharmacological treatment. Future research is needed to identify explanatory mechanisms underlying ongoing racial/ethnic variation to target potential interventions.

Association of Race With Disease Expression and Clinical Outcomes Among Patients With Hypertrophic Cardiomyopathy

Importance

Racial differences are recognized in multiple cardiovascular parameters, including left ventricular hypertrophy and heart failure, which are 2 major manifestations of hypertrophic cardiomyopathy. The association of race with disease expression and outcomes among patients with hypertrophic cardiomyopathy is not well characterized.

Objective

To assess the association between race, disease expression, care provision, and clinical outcomes among patients with hypertrophic cardiomyopathy.

Design, Setting, and Participants

This retrospective cohort study included data on black and white patients with hypertrophic cardiomyopathy from the US-based sites of the Sarcomeric Human Cardiomyopathy Registry from 1989 through 2018.

Exposures

Self-identified race.

Main Outcomes and Measures

Baseline characteristics; genetic architecture; adverse outcomes, including cardiac arrest, cardiac transplantation or left ventricular assist device implantation, implantable cardioverter-defibrillator therapy, all-cause mortality, atrial fibrillation, stroke, and New York Heart Association (NYHA) functional class III or IV heart failure; and septal reduction therapies. The overall composite outcome consists of the first occurrence of any component of the ventricular arrhythmic composite end point, cardiac transplantation, left ventricular assist device implantation, NYHA class III or IV heart failure, atrial fibrillation, stroke, or all-cause mortality.

Results

Of 2467 patients with hypertrophic cardiomyopathy at the time of analysis, 205 (8.3%) were black (130 male [63.4%]; mean [SD] age, 40.0 [18.6] years) and 2262 (91.7%) were white (1351 male [59.7%]; mean [SD] age, 45.5 [20.5] years). Compared with white patients, black patients were younger at the time of diagnosis (mean [SD], 36.5 [18.2] vs 41.9 [20.2] years; P < .001), had higher prevalence of NYHA class III or IV heart failure at presentation (36 of 205 [22.6%] vs 174 of 2262 [15.8%]; P = .001), had lower rates of genetic testing (111 [54.1%] vs 1404 [62.1%]; P = .03), and were less likely to have sarcomeric mutations identified by genetic testing (29 [26.1%] vs 569 [40.5%]; P = .006). Implantation of implantable cardioverter-defibrillators did not vary by race; however, invasive septal reduction was less common among black patients (30 [14.6%] vs 521 [23.0%]; P = .007). Black patients had less incident atrial fibrillation (35 [17.1%] vs 608 [26.9%]; P < .001). Black race was associated with increased development of NYHA class III or IV heart failure (hazard ratio, 1.45; 95% CI, 1.08-1.94) which persisted on multivariable Cox proportional hazards regression (hazard ratio, 1.97; 95% CI, 1.34-2.88). There were no differences in the associations of race with stroke, ventricular arrhythmias, all-cause mortality, or the overall composite outcome.

Conclusions and Relevance

The findings suggest that black patients with hypertrophic cardiomyopathy are diagnosed at a younger age, are less likely to carry a sarcomere mutation, have a higher burden of functionally limited heart failure, and experience inequities in care with lower use of invasive septal reduction therapy and genetic testing compared with white patients. Further study is needed to assess whether higher rates of heart failure may be associated with underlying ancestry-based disease pathways, clinical management, or structural inequities.

Sex-specific cardiac and vascular responses to hypertension in Chinese populations without overt cardiovascular diseases

OBJECTIVE

The aim of current study was to evaluate sex-specific cardiac and vascular responses to hypertension in Chinese populations without overt cardiovascular disease.

METHODS

This was a cross-sectional study and participants were enrolled in outpatient clinic between January 2017 and December 2019. Transthoracic echocardiographic measurements were performed to evaluate cardiac and vascular structure and function.

RESULTS

Among 486 participants, women account for 36.2% (n = 176). Compared to men, women were younger, had shorter duration of hypertension, and more likely to be abdominal obesity. Mean systolic and diastolic blood pressure (SBP and DBP) were similar, but women had higher mean pulse pressure (PP) than men. After adjustment for covariates, women had higher E/e' ratio and arterial elastance (Ea). The proportion of patients with concentric remodeling was higher in women (14.7% vs 9.5%). Increased SBP was associated with relative wall thickness (RWT), stroke volume (SV) index, E/e' ratio and Ea in both women and men, and the magnitude of the association between SBP and E/e' ratio was greater in women than in men (P_interaction = 0.04). Increased DBP was associated with RWT and Ea in both women and men with similar magnitude. Increased PP was associated with RWT, E/e' ratio and Ea in both women and men, and the magnitude of the association between PP and Ea was greater in women than in men (P_interaction = 0.03).

CONCLUSION

In conclusion, the current study indicates cardiac and vascular responses to hypertension are greater in women than in men, manifesting as an increased estimated LV filling pressure and arterial elastance in women.

Racial and Ethnic Differences in Biomarkers, Health Status, and Cardiac Remodeling in Patients With Heart Failure With Reduced Ejection Fraction Treated With Sacubitril/Valsartan

Supplemental Digital Content is available in the text.

Among patients with heart failure and reduced ejection fraction (left ventricular (LV) ejection fraction ≤40%), sacubitril/valsartan (S/V) treatment is associated with improved health status and reverse cardiac remodeling. Data regarding racial and ethnic differences in response to S/V are lacking.

A novel method of calculating stroke volume using point-of-care echocardiography

Background

Point-of-care transthoracic echocardiography (POC-TTE) is essential in shock management, allowing for stroke volume (SV) and cardiac output (CO) estimation using left ventricular outflow tract diameter (LVOTD) and left ventricular velocity time integral (VTI). Since LVOTD is difficult to obtain and error-prone, the body surface area (BSA) or a modified BSA (mBSA) is sometimes used as a surrogate (LVOTD^BSA, LVOTD^mBSA). Currently, no models of LVOTD based on patient characteristics exist nor have BSA-based alternatives been validated.

Methods

Focused rapid echocardiographic evaluations (FREEs) performed in intensive care unit patients over a 3-year period were reviewed. The age, sex, height, and weight were recorded. Human expert measurement of LVOTD (LVOTD^HEM) was performed. An epsilon-support vector regression was used to derive a computer model of the predicted LVOTD (LVOTD^CM). Training, testing, and validation were completed. Pearson coefficient and Bland-Altman were used to assess correlation and agreement.

Results

Two hundred eighty-seven TTEs with ideal images of the LVOT were identified. LVOTD^CM was the best method of SV measurement, with a correlation of 0.87. LVOTD^mBSA and LVOTD^BSA had correlations of 0.71 and 0.49 respectively. Root mean square error for LVOTD^CM, LVOTD^mBSA, and LVOTD^BSA respectively were 13.3, 37.0, and 26.4. Bland-Altman for LVOTD^CM demonstrated a bias of 5.2. LVOTD^CM model was used in a separate validation set of 116 ideal images yielding a linear correlation of 0.83 between SV^HEM and SV^CM. Bland Altman analysis for SV^CM had a bias of 2.3 with limits of agreement (LOAs) of − 24 and 29, a percent error (PE) of 34% and a root mean square error (RMSE) of 13.9.

Conclusions

A computer model may allow for SV and CO measurement when the LVOTD cannot be assessed. Further study is needed to assess the accuracy of the model in various patient populations and in comparison to the gold standard pulmonary artery catheter. The LVOTD^CM is more accurate with less error compared to BSA-based methods, however there is still a percentage error of 33%. BSA should not be used as a surrogate measure of LVOTD. Once validated and improved this model may improve feasibility and allow hemodynamic monitoring via POC-TTE once it is validated.

Understanding the Complexity of Heart Failure Risk and Treatment in Black Patients

Although care of patients with heart failure (HF) has improved in the past decade, important disparities in HF outcomes persist based on race/ethnicity. Age-adjusted HF-related cardiovascular disease death rates are higher for Black patients, particularly among young Black men and women whose rates of death are 2.6- and 2.97-fold higher, respectively, than White men and women. Similarly, the rate of HF hospitalization for Black men and women is nearly 2.5-fold higher when compared with Whites, with costs that are significantly higher in the first year after HF hospitalization. While the relative rate of HF hospitalization has improved for other race/ethnic minorities, the disparity in HF hospitalization between Black and White patients has not decreased during the last decade. Although access to care and socioeconomic status have been traditional explanations for the observed racial disparities in HF outcomes, contemporary data suggest that novel factors including genetic susceptibility as well as social determinants of health and implicit bias may play a larger role in health outcomes than previously appreciated. The purpose of this review is to describe the complex interplay of factors that influence racial disparities in HF incidence, prevalence, and disease severity, with a highlight on evolving knowledge that will impact the clinical care and address future research needs to improve HF disparities in Blacks.

Transitioning from Preclinical to Clinical Heart Failure with Preserved Ejection Fraction: A Mechanistic Approach

To better understand heart failure with preserved ejection fraction (HFpEF), we need to better characterize the transition from asymptomatic pre-HFpEF to symptomatic HFpEF. The current emphasis on left ventricular diastolic dysfunction must be redirected to microvascular inflammation and endothelial dysfunction that leads to cardiomyocyte remodeling and enhanced interstitial collagen deposition. A pre-HFpEF patient lacks signs or symptoms of heart failure (HF), has preserved left ventricular ejection fraction (LVEF) with incipient structural changes similar to HFpEF, and possesses elevated biomarkers of cardiac dysfunction. The transition from pre-HFpEF to symptomatic HFpEF also involves left atrial failure, pulmonary hypertension and right ventricular dysfunction, and renal failure. This review focuses on the non-left ventricular mechanisms in this transition, involving the atria, right heart cavities, kidneys, and ultimately the currently accepted driver—systemic inflammation. Impaired atrial function may decrease ventricular hemodynamics and significantly increase left atrial and pulmonary pressure, leading to HF symptoms, irrespective of left ventricle (LV) systolic function. Pulmonary hypertension and low right-ventricular function are associated with the incidence of HF. Interstitial fibrosis in the heart, large arteries, and kidneys is key to the pathophysiology of the cardiorenal syndrome continuum. By understanding each of these processes, we may be able to halt disease progression and eventually extend the time a patient remains in the asymptomatic pre-HFpEF stage.

Racial Differences in Malignant Left Ventricular Hypertrophy and Incidence of Heart Failure: A Multicohort Study

BACKGROUND

A malignant subphenotype of left ventricular hypertrophy (LVH) has been described, in which minimal elevations in cardiac biomarkers identify individuals with LVH at high risk for developing heart failure (HF). We tested the hypothesis that a higher prevalence of malignant LVH among blacks may contribute to racial disparities in HF risk.

METHODS

Participants (n=15 710) without prevalent cardiovascular disease were pooled from 3 population-based cohort studies, the ARIC Study (Atherosclerosis Risk in Communities), the DHS (Dallas Heart Study), and the MESA (Multi-Ethnic Study of Atherosclerosis). Participants were classified into 3 groups: those without ECG-LVH, those with ECG-LVH and normal biomarkers (hs-cTnT (high sensitivity cardiac troponin-T) <6 ng/L and NT-proBNP (N-terminal pro-B-type natriuretic peptide) <100 pg/mL), and those with ECG-LVH and abnormal levels of either biomarker (malignant LVH). The outcome was incident HF.

RESULTS

Over the 10-year follow-up period, HF occurred in 512 (3.3%) participants, with 5.2% in black men, 3.8% in white men, 3.2% in black women, and 2.2% in white women. The prevalence of malignant LVH was 3-fold higher among black men and women versus white men and women. Compared with participants without LVH, the adjusted hazard ratio for HF was 2.8 (95% CI, 2.1-3.5) in those with malignant LVH and 0.9 (95% CI, 0.6-1.5) in those with LVH and normal biomarkers, with similar findings in each race/sex subgroup. Mediation analyses indicated that 33% of excess hazard for HF among black men and 11% of the excess hazard among black women was explained by the higher prevalence of malignant LVH in blacks. Of black men who developed HF, 30.8% had malignant LVH at baseline, with a corresponding population attributable fraction of 0.21. The proportion of HF cases occurring among those with malignant LVH, and the corresponding population attributable fraction, were intermediate and similar among black women and white men and lowest among white women.

CONCLUSIONS

A higher prevalence of malignant LVH may in part explain the higher risk of HF among blacks versus whites. Strategies to prevent development or attenuate risk associated with malignant LVH should be investigated as a strategy to lower HF risk and mitigate racial disparities.

Outcome in German and South African peripartum cardiomyopathy cohorts associates with medical therapy and fibrosis markers

AIMS

This study aims to compare the clinical course of peripartum cardiomyopathy (PPCM) cohorts from Germany (G-PPCM) and South Africa (SA-PPCM) with fibrosis-related markers to get insights into novel pathomechanisms of PPCM.

METHODS AND RESULTS

G-PPCM (n = 79) and SA-PPCM (n = 72) patients and healthy pregnancy-matched women from Germany (n = 56) and South Africa (n = 40) were enrolled. Circulating levels of procollagen type-I (PINP) and type-III (PIIINP) N-terminal propeptides, soluble ST2, galectin-3, and full-length and cleaved osteopontin (OPN) were measured at diagnosis (baseline) and 6 months of follow-up. Both cohorts received standard heart failure therapy while anticoagulation therapy was applied in 100% of G-PPCM but only in 7% of SA-PPCM patients. In G-PPCM patients, baseline left ventricular ejection fraction (LVEF) was lower, and outcome was better (baseline LVEF, 24 ± 8%, full recovery: 52%, mortality: 0%) compared with SA-PPCM patients (baseline LVEF: 30 ± 9%, full recovery: 32%, mortality: 11%; P < 0.05). At baseline, PINP/PIIINP ratio was lower in SA-PPCM and higher in G-PPCM compared with respective controls, whereas total OPN was elevated in both collectives. Cleaved OPN, which increases PIIINP levels, is generated by thrombin and was reduced in patients receiving anticoagulation therapy. High baseline galectin-3, soluble ST2, and OPN levels were associated with poor outcome in all PPCM patients.

CONCLUSIONS

SA-PPCM patients displayed a more profibrotic biomarker profile, which was associated with a less favourable outcome despite better cardiac function at baseline, compared with G-PPCM patients. Use of bromocriptine and anticoagulation therapy in G-PPCM may counteract fibrosis and may in part be responsible for their better outcome.

Differences in left ventricular geometry in hypertensive African-Europeans and Caucasian patients

BACKGROUND

There are data showing race-related differences regarding left ventricular (LV) geometry in hypertensive patients. Several authors reported that concentric remodeling is the most common remodeling pattern in hypertensive African-Americans, and this pattern may be related to prognosis. There is little information about the LV remodeling patterns in hypertensive Africans that migrated to Europe, which might have different distributions from those seen in African-Americans. The aim our study was to describe the prevalence of LV remodeling patterns in hypertensive African-Europeans and to compare it with that of hypertensive Caucasians.

METHODS

This is a descriptive study that included 135 consecutive treated hypertensive African-Europeans and 128 hypertensive Caucasians. Patients were examined by transthoracic echocardiography and categorized into the four classic geometric patterns according to LV mass index (LVMi) and relative wall thickness (RWT).

RESULTS

The mean age and gender distribution were similar in the 2 groups. Caucasians had significantly higher body mass index, LV diastolic and systolic diameters, while African-Europeans had higher RWT and interventricular septum thickness. No differences in LVMi was found. In the African-European group, the prevalence of normal pattern, concentric remodeling, concentric hypertrophy and eccentric hypertrophy were 13%, 36%, 45% and 6% respectively, while in Caucasians they were 21%, 33%, 34% and 12%, respectively. African-Europeans had a higher prevalence of concentric remodeling and hypertrophy compared to Caucasians (81% vs. 67%, p = .005).

CONCLUSIONS

This study shows important differences in LV geometry between treated African-European and Caucasian hypertensive patients. Also, African-Europeans may have slightly different characteristics compared to African-Americans.

Cumulative blood pressure from early adulthood to middle age is associated with left atrial remodelling and subclinical dysfunction assessed by three-dimensional echocardiography: a prospective post hoc analysis from the coronary artery risk development in young adults study

Aims

To evaluate the association of cumulative blood pressure (BP) from young adulthood to middle age with left atrial (LA) structure/function as assessed by three-dimensional echocardiography (3DE) in a large longitudinal bi-racial population study.

Methods and results

We conducted a prospective post hoc analysis of individuals enrolled at the Coronary Artery Risk Development in Young Adults, which is a multi-centre bi-racial cohort with 30 years of follow-up. Cumulative systolic and diastolic BP levels were defined by summing the product of average millimetres of mercury and the years between each two consecutive clinic visits over 30 years of follow-up. Multivariable linear regression analyses were used to assess the relationship between cumulative systolic and diastolic BP with 3DE LA structure and function, adjusting for demographics and traditional cardiovascular risk factors. A total of 1033 participants were included, mean age was 55.4 ± 3.5 years, 55.2% women, 43.9% blacks. Cumulative systolic BP had stronger correlations than cumulative diastolic BP. Higher cumulative systolic BP was independently associated with higher 3D LA volumes: maximum (β = 1.74, P = 0.004), pre-atrial contraction (β = 1.87, P < 0.001), minimum (β = 0.76, P = 0.04), total emptying (β = 0.98, P = 0.006), active emptying (β = 1.12, P < 0.001), and lower magnitude 3D LA early diastolic strain rate (β = 0.05, P = 0.02). Higher cumulative diastolic BP was independently associated with higher 3D LA active emptying volume (β = 0.66, P = 0.002), lower magnitude 3D LA early diastolic strain rate (β = 0.05, P = 0.004), and higher magnitude 3D LA late diastolic strain rate (β = -0.04, P = 0.05).

Conclusion

Higher cumulative BP from early adulthood throughout middle age was associated with adverse LA remodelling evaluated by 3D echocardiography.

Racial Differences in Characteristics and Outcomes of Patients With Heart Failure and Preserved Ejection Fraction in the Treatment of Preserved Cardiac Function Heart Failure Trial

Background:

Black patients have been shown to have different baseline characteristics and outcomes compared with nonblack patients in cohort studies. However, few studies have focused on heart failure (HF) with preserved ejection fraction (HFpEF) patients. We aimed to determine the difference in cardiovascular outcomes in black and nonblack patients with HFpEF and to determine the relative efficacy and safety of spironolactone in black and nonblack patients.

Methods and Results:

Patients with HFpEF, randomized to spironolactone versus placebo in the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) in North and South America, were grouped according to self-described black and nonblack race. Black HFpEF patients (n=302) were younger and were more likely to have diabetes mellitus and hypertension than nonblack patients but had similar HFpEF severity. Black patients had higher risk for the primary outcome (hazard ratio [HR], 1.34; 95% confidence interval, 1.06–1.71; P =0.02) and first HF hospitalization (HR, 1.51; 95% confidence interval, 1.167–1.97; P =0.002)], but no significant difference in cardiovascular mortality risk (HR, 0.78; 95% confidence interval, 0.51–1.20; P =0.326). In black and nonblack patients, randomization to spironolactone conferred similar efficacy in the primary outcome (HR, 0.83 versus 0.79; P for interaction=0.49), HF hospitalization (HR, 0.67 versus 0.82; P for interaction=0.76), and cardiovascular mortality ( P for interaction=0.19). The risk of hyperkalemia and worsening renal function with spironolactone and study drug adherence were also similar.

Conclusions:

Black patients with HFpEF have a higher HF hospitalization risk than nonblack patients, but spironolactone is similarly effective and safe in both groups.

Clinical Trial Registration:

URL: https://www.clinicaltrials.gov . Unique identifier: NCT00094302.