Progression of coronary atherosclerosis in African-American patients

Racial disparity in atherosclerotic cardiovascular disease in hospitalized patients with diabetes 2005-2015: Potential warning signs for future U.S. public health

Introduction

The pattern of atherosclerotic cardiovascular disease (ASCVD) and diabetes driven hospitalizations in the United States (U.S.) is unclear. We attempted to identify the disparate outcome in race related ASCVD hospitalizations with comorbid diabetes.

Methods

Adults aged ≥40 years old with ASCVD (acute coronary syndrome (ACS), coronary artery disease (CAD), stroke, or peripheral arterial disease (PAD)) as the first-listed diagnosis with comorbid diabetes as a secondary diagnosis were determined using the U.S. 2005-2015 National (Nationwide) Inpatient Sample (NIS) data. The incidence of other modifiable cardiovascular risk factors (hypertension, dyslipidemia, smoking/substance abuse, obesity, and renal failure), in hospital procedures and outcomes was estimated. Complex samples multivariate regression was used to determine the odds ratio (OR) with 95% confidence Interval (CI) of risk associations and to determine patient comorbidity adjusted ASCVD related in-hospital mortality rate.

Results

The rate of total ASCVD hospitalizations with comorbid diabetes adjusted to the U.S. census population increased by 5.7% for black men compared to 4% for black women. There was a higher odd of an ASCVD hospitalization if there was comorbid hypertension (Odds Ratio (OR 1.29; 95% CI 95% 1.28-1.31), dyslipidemia (OR 2.03; 95% CI 2.01-2.05), renal failure (OR 1.84; 95% CI 1.82-1.86), and smoking/substance use disorder (OR 1.31; 95% CI 1.29-1.33). White Women had the highest risk-adjusted incidence of ASCVD related in-hospital mortality (4.2%) relative to black women (3.9%), compared to white men (3.6%) and black men (3.5%) respectively.

Conclusions

Despite improving treatment options for ASCVD in the diabetic population, blacks with diabetes continue to have a higher hospitalization burden with a concomitant disparity in comorbid presentation and outcome. Further evaluation is the need to understand these associations.

Imaging plaque inflammation in asymptomatic cocaine addicted individuals with simultaneous positron emission tomography/magnetic resonance imaging

BACKGROUND

Chronic cocaine use is associated with stroke, coronary artery disease and myocardial infarction, resulting in severe impairments or sudden mortality. In the absence of clear cardiovascular symptoms, individuals with cocaine use disorder (iCUD) seeking addiction treatment receive mostly psychotherapy and psychiatric pharmacotherapy, with no attention to vascular disease (i.e., atherosclerosis). Little is known about the pre-clinical signs of cardiovascular risk in iCUD and early signs of vascular disease are undetected in this underserved population.

AIM

To assess inflammation, plaque burden and plaque composition in iCUD aiming to detect markers of atherosclerosis and vascular disease.

METHODS

The bilateral carotid arteries were imaged with positron emission tomography/magnetic resonance imaging (PET/MRI) in iCUD asymptomatic for cardiovascular disease, healthy controls, and individuals with cardiovascular risk. PET with 18F-fluorodeoxyglucose (¹⁸F-FDG) evaluated vascular inflammation and 3-D dark-blood MRI assessed plaque burden including wall area and thickness. Drug use and severity of addiction were assessed with standardized instruments.

RESULTS

The majority of iCUD and controls had carotid FDG-PET signal greater than 1.6 but lower than 3, indicating the presence of mild to moderate inflammation. However, the MRI measure of wall structure was thicker in iCUD as compared to the controls and cardiovascular risk group, indicating greater carotid plaque burden. iCUD had larger wall area as compared to the healthy controls but not as compared to the cardiovascular risk group, indicating structural wall similarities between the non-control study groups. In iCUD, wall area correlated with greater cocaine withdrawal and craving.

CONCLUSION

These preliminary results show markers of carotid artery disease burden in cardiovascular disease-asymptomatic iCUD. Broader trials are warranted to develop protocols for early detection of cardiovascular risk and preventive intervention in iCUD.

Imaging of coronary atherosclerosis in various susceptible groups

Coronary artery disease (CAD) is the leading cause of death and disability worldwide. Atherosclerosis, which is the primary pathophysiologic mechanism for the development of plaque leading to CAD, is a multifactorial process resulting from a complex interplay between genetic susceptibility and various risk factors such as hypertension (HT), dyslipidaemia, diabetes mellitus (DM) and smoking. In addition, influences from other disease states such as chronic kidney disease (CKD), obesity and the metabolic syndrome as well as gender and ethnic diversity also contribute to the disease process. Insights from pathological observations and advances in cellular and molecular biology have helped us understand the process of plaque formation, progression and rupture leading to events. Several intravascular imaging techniques such as intravascular ultrasound (IVUS), Virtual histology IVUS (VH-IVUS) and optical coherence tomography (OCT) allow in vivo assessment of plaque burden, plaque morphology and response to therapy. In addition, non invasive assessment using coronary artery calcium (CAC) score allows risk stratification and plaque burden assessment whilst computed tomography coronary angiography (CTCA) allows evaluation of luminal stenosis, plaque characterisation and quantification. This review aims to summarise the results of invasive and non-invasive imaging studies of coronary atherosclerosis seen in various high-risk populations including DM, metabolic syndrome, obesity, CKD and, gender differences and ethnicity. Understanding the phenotype of plaques in various susceptible groups may allow potential development of personalised therapies.

[Progression and regression of atherosclerotic plaques. New results based on intracoronary ultrasound]

Intravascular ultrasound has been established as the gold standard for analyzing alterations in coronary artery atherosclerosis during monitoring investigations. Cross-sectional imaging can be used to visualize the area of the lumen and the vessel size and the plaque size as the difference between them. New technology allows the 3-D reconstruction of the volume for prespecified vessel segments using specific algorithms. Investigations on the natural course demonstrated predominantly progression. Even regression of coronary atherosclerosis can be visualized and quantified. Regression can only be expected when the level of low-density lipoprotein (LDL) cholesterol is below the critical level of 75 mg/dl. Prospective randomized studies with highly effective statins showed that regression occurred in up to two thirds of patients when LDL cholesterol was below a cut-off of 78 mg/dl and was, therefore, very close to the threshold, which was calculated based on investigations of the natural course. Although the absolute values for plaque volume are in the range of 1 % over 1-2 years, it must be taken into consideration that coronary artery diseases are chronic diseases and a 1 % change per year will correspond to an enormous effect on plaque growth of coronary vessels. The great success of statins in reducing cardiovascular events is due to the possibility for reduction of progression and induction of regression. New developments in medication will be measured against the effectiveness of statins.

Disparities in patients presenting to the emergency department with potential acute coronary syndrome: it matters if you are Black or White

OBJECTIVES

To explore disparities between non-Hispanic Blacks and non-Hispanic Whites presenting to the emergency department (ED) with potential acute coronary syndrome (ACS).

BACKGROUND

Individuals with fewer resources have worse health outcomes and these individuals are disproportionately those of color.

METHODS

This prospective study enrolled 663 patients in four EDs. Clinical presentation, treatment, and patient-reported outcome variables were measured at baseline, 1, and 6 months.

RESULTS

Blacks with confirmed ACS were younger; had lower income; less education; more risk factors; more symptoms, and longer prehospital delay at presentation compared to Whites. Blacks experiencing palpitations, unusual fatigue, and chest pain were more than 3 times as likely as Whites to have ACS confirmed. Blacks with ACS had more clinic visits and more symptoms 1 month following discharge.

CONCLUSIONS

Significant racial disparities remain in clinical presentation and outcomes for Blacks compared to Whites presenting to the ED with symptoms suggestive of ACS.

Protein kinase C regulation of GABAA receptors

Pharmacological studies with drugs that activate or inhibit several protein kinase C (PKC) isozymes have identified the PKC family of serine-threonine kinases as important in the regulation of gamma-aminobutyric acid type A (GABA(A)) receptor function. PKC modulates GABA(A) receptor surface density, chloride conductance and receptor sensitivity to positive allosteric modulators such as neurosteroids, ethanol, benzodiazepines and barbiturates. Recent studies using PKC isozyme-selective reagents and gene-targeted mice have begun to identify critical roles for three isozymes, PKCbetaII, PKCvarepsilon and PKCgamma, in various aspects of GABA(A) receptor regulation. Progress in this field touches upon therapeutic areas that are of great clinical importance such as anxiety and addiction. Increased understanding of how PKC regulates GABA(A) receptors and which PKC isozymes are involved holds promise for development of new treatments for diverse neuropsychiatric disorders.