Matrix Gla protein and the long-term incidence and progression of coronary artery and aortic calcification in the Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND AIMS

Matrix Gla protein (MGP) is an inhibitor of calcification that requires carboxylation by vitamin K for activity. The inactive form of MGP, dephosphorylated-uncarboxylated matrix Gla protein (dp-ucMGP), has been associated with increased calcification. However, it is not known whether there is a longitudinal relationship between dephosphorylated-uncarboxylated matrix Gla protein levels and coronary and aortic calcification in large population cohorts.

METHODS

The Multi-Ethnic Study of Atherosclerosis (MESA) followed participants with serial cardiac computed tomography (CT) measures of vascular calcification. Dp-ucMGP was measured at baseline in a subset of participants who completed baseline and follow-up CTs approximately 10 years later and had available plasma specimens (n = 2663). Linear mixed effects models (LMMs) were used to determine the association of dp-ucMGP with the simultaneous incidence and progression of coronary artery, ascending thoracic aortic, or descending thoracic aortic calcification (CAC, ATAC, DTAC)].

RESULTS

For every one standard deviation (SD, 178 pmol/L) increment in dp-ucMGP, CAC increased by 3.44 ([95% CI = 1.68, 5.21], p < 0.001) Agatston units/year (AU/year), ATAC increased by 0.63 ([95% CI = 0.27, 0.98], p = 0.001) AU/year, and DTAC increased by 8.61 ([95% CI = 4.55, 12.67], p < 0.001) AU/year. The association was stronger for DTAC in those ≥65 years and with diabetes.

CONCLUSIONS

We found a positive association of the inactive form of matrix Gla protein, dp-ucMGP, and long-term incidence/progression of CAC, ATAC, and DTAC. Future studies should investigate dp-ucMGP as a calcification regulator and MGP as a possible therapeutic target to slow progression of calcification in the vasculature.

Sex differences in the well-being of interventional cardiologists

Several studies suggest differences in burnout and coping mechanisms between female and male physicians. We conducted an international, online survey exploring sex-based differences in the well-being of interventional cardiologists. Of 1251 participants, 121 (9.7%) were women. Compared with men, women were more likely to be single and under 50 years old, and they asked more often for development opportunities and better communication with administration. Overall burnout was similar between women and men, but women interventional cardiology attendings were more likely to think that they were achieving less than they should. Improved communication with administration and access to career development opportunities may help prevent or mitigate burnout in women interventional cardiologists.

Sex differences in the well-being of interventional cardiologists

Several studies suggest differences in burnout and coping mechanisms between female and male physicians. We conducted an international, online survey exploring sex-based differences in the well-being of interventional cardiologists. Of 1251 participants, 121 (9.7%) were women. Compared with men, women were more likely to be single and under 50 years old, and they asked more often for development opportunities and better communication with administration. Overall burnout was similar between women and men, but women interventional cardiology attendings were more likely to think that they were achieving less than they should. Improved communication with administration and access to career development opportunities may help prevent or mitigate burnout in women interventional cardiologists.

Characteristics and outcomes of socioeconomically disadvantaged pregnant individuals with adult congenital heart disease presenting to a Cardio-Obstetrics Program

BACKGROUND

Outcomes of individuals with adult congenital heart disease who are socioeconomically disadvantaged and cared for in cardio-obstetrical programs, are lacking.

OBJECTIVE

This study aimed to describe the clinical characteristics, maternal pregnancy outcomes, and contraceptive uptake in individuals with adult congenital heart disease in an urban cardio-obstetrical program.

STUDY DESIGN

Retrospective data were collected for individuals with adult congenital heart disease seen in the Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System between 2015 and 2021 and compared using modified World Health Organization class I, II vs the modified World Health Organization class ≥II/III.

RESULTS

Over 90% of individuals with adult congenital heart disease were pregnant at the time of referral. Modified World Health Organization class I, II (n=77, 62.4% Black or Hispanic/Latina) had a total of 94 pregnancies and modified World Health Organization class ≥II/III (n=49, 49.0% Black or Hispanic/Latina) had a total of 56 pregnancies. Over 25% of individuals in each group had a body mass index ≥30 (P=.78), and very low summary socioeconomic scores. Modified World Health Organization class ≥II/III were more likely to be anticoagulated in the first trimester than modified World Health Organization class I, II (10.7% vs 0.0%, P=.002) and throughout pregnancy (14.3% vs 3.2% P=.02). Modified World Health Organization class ≥II/III were more likely to require arterial monitoring during delivery than modified World Health Organization class I, II (14.3% vs 0.0%, P=.001) or delivery under general anesthesia (8.9% vs 1.1%, P=.03) but had a comparable frequency of cesarean delivery (35.8% vs 41.3%, P=.68). There were no in-hospital maternal deaths. There was no difference in the type of contraception recommended by modified World Health Organization class, however, modified World Health Organization class ≥II/III were more likely to receive long-acting types or permanent sterilization (35.6% vs 54.6%, P=.045).

CONCLUSION

In a socioeconomically disadvantaged cohort with adult congenital heart disease from a historically marginalized community, those with modified World Health Organization class ≥II/III had more complex antepartum and intrapartum needs but similar maternal and obstetrical outcomes as modified World Health Organization class I, II. The multidisciplinary approach offered by a cardio-obstetrics program may contribute to successful outcomes in this high-risk cohort, and these data are hypothesis-generating.

A Geriatric Approach to Percutaneous Coronary Interventions in Older Adults, Part II: A JACC: Advances Expert Panel

We review a comprehensive risk assessment approach for percutaneous coronary interventions in older adults and highlight the relevance of geriatric syndromes within that broader perspective to optimize patient-centered outcomes in interventional cardiology practice. Reflecting the influence of geriatric principles in older adults undergoing percutaneous coronary interventions, we propose a "geriatric" heart team to incorporate the expertise of geriatric specialists in addition to the traditional heart team members, facilitate uptake of the geriatric risk assessment into the preprocedural risk assessment, and address ways to mitigate these geriatric risks. We also address goals of care in older adults, highlighting common priorities that can impact shared decision making among older patients, as well as frequently encountered pharmacotherapeutic considerations in the older adult population. Finally, we clarify gaps in current knowledge and describe crucial areas for future investigation.

Assessment and Management of Older Adults Undergoing PCI, Part 1: A JACC: Advances Expert Panel

As the population ages, older adults represent an increasing proportion of patients referred to the cardiac catheterization laboratory. Older adults are the highest-risk group for morbidity and mortality, particularly after complex, high-risk percutaneous coronary interventions. Structured risk assessment plays a key role in differentiating patients who are likely to derive net benefit vs those who have disproportionate risks for harm. Conventional risk assessment tools from national cardiovascular societies typically rely on 3 pillars: 1) cardiovascular risk; 2) physiologic and hemodynamic risk; and 3) anatomic and procedural risks. We propose adding a fourth pillar: geriatric syndromes, as geriatric domains can supersede all other aspects of risk.

Extracardiac Prothrombotic Effects of COVID-19

COVID-19 infection triggers a heightened inflammatory response which in turn, increases thrombosis and thromboembolism. Microvascular thrombosis has been detected in various tissue beds which may account for some of the multi-system organ dysfunction associated with COVID-19. Additional research is needed to understand which prophylactic and therapeutic drug regimens are best for the prevention and treatment of thrombotic complications of COVID-19.

Women’s Cardiovascular Health: Prioritizing the Majority Minority

Women make up the majority of the global population, and [...]

Educational Experience of Interventional Cardiology Fellows in the United States and Canada

BACKGROUND

The COVID-19 pandemic and iodinated contrast shortage may have affected interventional cardiology (IC) fellowship training.

OBJECTIVES

The aim of this study was to investigate the educational experience of first-year IC fellows in the United States and Canada.

METHODS

A 59-question online survey was conducted among 2021-2022 first-year IC fellows in the United States and Canada.

RESULTS

Of the 360 IC fellows invited to participate, 111 (31%) responded; 95% were from the United States, and 79% were men. Participants were mostly from university programs (70%), spent 61 to 70 hours/week in the hospital, and had an annual percutaneous coronary intervention case number of <200 (5%), 200 to 249 (8%), 250 to 349 (33%), 350 to 499 (39%), 500 to 699 (12%), or ≥700 (3%). For femoral access, a micropuncture needle was used regularly by 89% and ultrasound-guided puncture by 81%, and 43% used vascular closure devices in most cases (>80%). Intravascular ultrasound was performed and interpreted very comfortably by 62% and optical coherence tomography (OCT) by 32%, and 20% did not have access to OCT. Approximately one-third felt very comfortable performing various atherectomy techniques. Covered stents, fat embolization, and coil embolization were used very comfortably by 14%, 4%, and 3%, respectively. Embolic protection devices were used very comfortably by 11% to 24% of IC fellows. Almost one-quarter of fellows (24%) were warned about their high radiation exposure. Eighty-four percent considered IC fellowship somewhat or very stressful, and 16% reported inadequate psychological support.

CONCLUSIONS

This survey highlights opportunities for improvement with regard to the use of intravascular imaging, atherectomy techniques, complication prevention and management strategies, radiation awareness and mitigation, and psychological support.

Effect of cooling methods and target temperature on outcomes in comatose patients resuscitated from cardiac arrest: Systematic review and network meta-analysis of randomized trials

BACKGROUND

Targeted temperature management (TTM) has been recommended after cardiac arrest (CA), however the specific temperature targets and cooling methods (intravascular cooling (IVC) versus surface cooling (SC)) remain uncertain.

METHODS

PUBMED and EMBASE were searched until October 8, 2022 for randomized clinical trials (RCTs) investigating the efficacy of TTM after CA. The randomized treatment arms were categorized into the following 6 groups: 31..C to 33..C IVC, 31..C to 33..C SC, 34..C to 36..C IVC, 34..C to 36..C SC, strict normothermia or fever prevention (Strict NT or FP), and standard of care without TTM (No-TTM). The primary outcome was neurological recovery. P-score was used to rank the treatments, where a larger value indicates better performance.

RESULTS

We identified 15 RCTs, involving 5,218 patients with CA. Compared to No-TTM as the reference, the other therapeutic options significantly improved neurological outcomes (vs No-TTM; 31..C to 33..

C IVC

RR = 0.67, 95% CI 0.54 to 0.83; 31..C to 33..C SC RR = 0.73, 95% CI 0.61 to 0.87; 34..C to 36..

C IVC

RR = 0.66, 95% CI 0.51 to 0.86; 34..C to 36..C SC: RR = 0.73, 0.59 to 0.90; Strict NT or FP: RR = 0.75, 95% CI 0.62 to 0.90). Overall, 31-33..C IVC had the highest probability to be the best therapeutic option to improve outcomes (the ranking P-score of 0.836). As a subgroup analysis, the ranking P-score showed that IVC might be a better cooling method compared to SC (IVC vs SC P-score: 0.960 vs 0.670).

CONCLUSIONS

Hypothermia (31..C to 36..C IVC and SC) and active normothermia (Strict-NT and Strict-FP) were associated with better neurological outcomes compared to No-TTM, with IVC having a greater probability of being the better cooling method than SC.

High-Density Lipoprotein and Long-Term Incidence and Progression of Aortic Valve Calcification: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Aortic valve calcification (AVC) shares pathological features with atherosclerosis. Lipoprotein components have been detected in aortic valve tissue, including HDL (high-density lipoprotein). HDL measures have inverse associations with cardiovascular disease, but relationships with long-term AVC progression are unclear. We investigated associations of HDL cholesterol, HDL-particle number and size, apoC3-defined HDL subtypes, and, secondarily, CETP (cholesteryl ester transfer protein) mass and activity, with long-term incidence and progression of AVC.

METHODS

We used linear mixed-effects models to evaluate the associations of baseline HDL indices with AVC. AVC was quantified by Agatston scoring of up to 3 serial computed tomography scans over a median of 8.9 (maximum 11.2) years of follow-up in the Multi-Ethnic Study of Atherosclerosis (n=6784).

RESULTS

After adjustment, higher concentrations of HDL-C (high-density lipoprotein cholesterol), HDL-P (HDL particles), large HDL-P, and apoC3-lacking HDL-C were significantly associated with lower incidence/progression of AVC. Neither small or medium HDL-P nor apoC3-containing HDL-C was significantly associated with AVC incidence/progression. When included together, a significant association was observed only for HDL-C, but not for HDL-P. Secondary analyses showed an inverse relationship between CETP mass, but not activity, and AVC incidence/progression. In exploratory assessments, inverse associations for HDL-C, HDL-P, large HDL-P, and apoC3-lacking HDL with AVC incidence/progression were more pronounced for older, male, and White participants. ApoC3-containing HDL-C only showed a positive association with AVC in these subgroups.

CONCLUSIONS

In a multiethnic population, HDL-C, HDL-P, large HDL-P, and apoC3-lacking HDL-C were inversely associated with long-term incidence and progression of AVC. Further investigation of HDL composition and mechanisms could be useful in understanding pathways that slow AVC.

Maternal Outcomes in Women with Peripartum Cardiomyopathy versus Age and Race-Matched Peers in an Urban US Community

Peripartum cardiomyopathy (PPCM) is idiopathic systolic congestive heart failure around pregnancy. Comparisons with matched controls are lacking. We investigated maternal characteristics and outcomes up to 12 months in a cohort admitted to Montefiore Health System in Bronx, New York 1999−2015 (n = 53 cases and n = 92 age and race-matched controls, >80% Black or Hispanic/Latina). Compared to peers, women with PPCM had more chronic hypertension (24.5% vs. 8.8%, p = 0.001), prior gestational hypertension (20.8% vs. 5.4%, p = 0.001), prior preeclampsia (17.0% vs. 3.3%, p = 0.001), familial dilated cardiomyopathy (5.7% vs. 0.0%, p = 0.04), smoking (15.1% vs. 2.2%, p = 0.001), lower summary socioeconomic scores (−4.12 (IQR −6.81, −2.13) vs. −1.62 (IQR −4.20, −0.74), p < 0.001), public insurance (67.9% vs. 29.3% p = 0.001), and frequent depressive symptoms. Women with PPCM were often admitted antepartum (34.0% vs. 18.5%, p = 0.001) and underwent Cesarean section (65.4% vs. 30.4%, p = 0.001), but had less preterm labor (27.3% vs. 51.1%, p = 0.001). Women were rarely treated with bromocriptine (3.8%), frequently underwent left ventricular assist device placement (9.4% and n = 2 with menorrhagia requiring transfusion and progesterone) or heart transplantation (3.8%), but there were no in-hospital deaths. In sum, women with PPCM had worse socioeconomic disadvantage and baseline health than matched peers. Programs addressing social determinants of health may be important for women at high risk of PPCM.

Race-Ethnic Differences of ST-Elevation Myocardial Infarction: Findings from a New York Health System Registry

Background

Race and ethnicity are major considerations in the incidence, management, and long-term outcome of ST-elevation myocardial infarction (STEMI) in the United States, but there is limited existing comparative data.

Methods

We assembled a registry in a health system serving Bronx, NY of STEMI patients from 2008-2014 and analyzed differences in presentation, treatment and mortality between Hispanic/Latino (H/L), non-Hispanic Black (NHB) and non-Hispanic White (NHW). Upon discharge post-treatment for STEMI, all patients were followed for a median of 4.4 years (interquartile range 2.5, 6.0). Out of 966 STEMI patients, mean age was 61 years, 46% were H/L and 65% were male. H/Ls and NHBs had a higher prevalence of hypertension and diabetes mellitus than their NHW counterparts, coinciding with a lower socioeconomic status (SES).

Results

The number of critically diseased vessels found at cardiac catheterization and mean troponin levels did not vary by race-ethnicity; neither did the adjusted hazard ratios (HR) for death. However, age-sex adjusted rates of general hospital readmission were higher in NHBs vs NHWs (HR 1.30, P=.03). Age-sex adjusted cardiovascular readmissions rates were higher in H/Ls than NHWs (HR 1.42, P=.03). Age-sex adjusted heart failure readmissions were increased for both H/Ls (HR 2.14, P=.01) and NHBs (HR 2.12, P=.02) over NHWs.

Conclusions

Among STEMI patients, a higher prevalence of modifiable cardiovascular risk factors and a lower SES was seen among NHBs and H/Ls compared to NHWs. Despite similar coronary disease severity and in-hospital death, NHBs and H/Ls had a greater risk of general, cardiovascular and heart failure readmissions post-STEMI compared to NHWs.

Measures of high-density lipoprotein function in men and women with severe aortic stenosis

Background

Calcification of the aortic valve is a common heart valve disorder, in some cases leading to clinically impactful severe aortic stenosis (AS). Sex-specific differences in aortic valve calcification (ACV) exist, with women having a lower burden of calcification than men as measured by computed tomography; however, the pathophysiological mechanism that leads to these differences remains unclear.

Methods

Using cultured human Tamm-Horsfall protein 1 (THP-1) macrophages and human aortic valve interstitial cells, the effects of high-density lipoprotein (HDL) particles isolated from the plasma of men and women with severe AS were studied for cholesterol efflux capacity (CEC).

Results

HDL-CEC was assessed in 46 patients with severe AS, n = 30 men, n = 16 women. ATP-Binding Cassette A1 (ABCA1)-mediated HDL-CEC was measured from human cultured THP-1 macrophages to plasma HDL samples. Women with severe AS had more ABCA1-mediated HDL-CEC, as compared to men (8.50 ± 3.90% cpm vs. 6.80 ± 1.50% cpm, P = 0.04). HDL pre-β1 and α-particles were higher in woman than in men by spectral density, (pre-β1 HDL, 20298.29 ± 1076.15 vs. 15,661.74 ± 789.00, P = 0.002, and α-HDL, 63006.35 ± 756.81 vs. 50,447.00 ± 546.52, P = 0.03). Lecithin-cholesterol acyltransferase conversion of free cholesterol into cholesteryl esters was higher in women than men (16.44 ± 9.11%/h vs. 12.00 ± 8.07%/h, P = 0.03).

Conclusions

Sex-specific changes in various parameters of HDL-CEC were found in patients with severe AS. Sex-based modifications in HDL functionality by HDL-CEC might account for the reduced burden of calcification in women vs. men with severe AS. Therefore, future studies should target sex-related pathways in AS to help to improve understanding and treatment of AS.

Graphical abstract

Sex specifc differences in AVC and differences associated with HDL function in men and women with severe AS. When compared to men, women had higher preβ-HDL and α-HDL migrating particles, higher cholesterol efflux to HDL, and higher lecithin cholesterol acyl transferase (LCAT) activity, possibly indicating that improved reverse cholesterol transport may be protective against worsened calcification.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12944-022-01653-7.

Residual SYNTAX II Score and long-term outcomes post-ST-elevation myocardial infarction in an urban US cohort: the Montefiore STEMI Registry

BACKGROUND

Higher residual anatomic disease was associated with increased mortality in a recent randomized controlled trial of revascularization after ST-elevation myocardial infarction (STEMI). Less is known about the impact of residual disease post-STEMI in race-ethnic minorities.

METHODS

Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX)- II (SS-II) score is an established scoring method for anatomic disease and prevalent co-morbidities to describe patient complexity. We evaluated residual (r) SS-II in 165 patients from a single center urban US registry (n = 1208) presenting for primary percutaneous coronary intervention of STEMI and treated for 3-vessel or left main and any combination of 0, 1, 2 or 3-vessel disease.

RESULTS

The median age was 62 years (IQR 52-70), 29.1% women, 44.9% Hispanic/Latino and 19.4% non-Hispanic Black. Over median of 4.9 years (IQR 2.9-6.3), higher rSS-II was associated with increased death [hazard ratio 2.46 per SD increment in log rSS-II (~five-fold increment on the original scale) 95% CI 1.51, 3.99], death or all-cause readmission (hazard ratio 1.37 per SD increment in log rSS-II 95% CI, 1.11-1.70) and death or cardiovascular disease readmission (hazard ratio 1.46 per SD increment in log rSS-II 95% CI, 1.14-1.88). rSS-II was higher in older women with more co-morbidities, but not different by race-ethnicity.

CONCLUSIONS

In summary, higher rSS-II was associated with long-term outcomes post-STEMI in a prospective urban, minority cohort, suggesting a potential role for risk stratification with this measure in a non-trial setting.

Durable Polymer Drug Eluting Stent-Induced Kounis Syndrome and Eosinophilia Requiring Long-term Immunosuppression

There are no reports of systemic eosinophilic reactions to durable polymer coated drug eluting stents (DP-DES) and a consensus statement indicates that these devices should be considered in nickel allergy. We present a case of in-stent thrombosis, eosinophilia, and rash consistent with allergic myocardial infarction, a presentation of Kounis syndrome, in the context of metal allergy to DP-DES requiring long-term immunosuppression.

We present a case of in-stent thrombosis and eosinophilia consistent with Kounis syndrome, in the context of metal allergy to durable polymer coated drug eluting stents, requiring long-term immunosuppression.

Fetal Supraventricular Tachycardia: What the Adult Cardiologist Needs to Know

Fetal supraventricular tachycardia management is challenging, with consequences for both the fetus and the mother. If left untreated, fetal hydrops may ensue, at which point delivery and treatment of the arrhythmia is preferred. However, if the fetus is not at term nor near-term, significant doses of antiarrhythmics may be needed to achieve adequate transplacental bioavailability. Although digoxin has classically been the mainstay of treatment, the use of flecainide or sotalol as monotherapy or in combination with digoxin is being studied. Interdisciplinary team management and shared decision-making between the physician and patient are key to achieving successful outcomes. Adult cardiologists, particularly inpatient consultation services or through burgeoning cardio-obstetrics programs, may, in some practice settings, be asked to evaluate or comanage pregnant women with fetal arrhythmia.

Bone mineral density and long-term progression of aortic valve and mitral annular calcification: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND AIMS

Bone and mineral metabolism has been implicated in the pathophysiology of cardiac valve calcification. Whether bone demineralization, a common aging-related disorder, promotes calcific valve disease remains uncertain. We tested the hypothesis that low bone mineral density (BMD) is associated with greater incidence/progression of cardiac valve calcification in the Multi-Ethnic Study of Atherosclerosis.

METHODS

Using linear mixed-effects models, we related baseline measurement of BMD of the thoracic vertebrae by computed tomography (CT) in 6768 participants to serial CT assessments of aortic valve calcification (AVC) and mitral annular calcification (MAC) obtained over a >10-year period.

RESULTS

After multivariable adjustment, lower BMD (per SD decrement) was associated with accelerated increase in AVC over time in women (0.76 [95% CI 0.42,1.09] Agatston -units [AU]/year) and men (1.41 [95% CI 0.48,2.33] AU/year), as well as for MAC in women (3.22 [95% CI 1.16,5.28] AU/year) and men (3.59 [95% CI 2.09,5.09] AU/year). Significant effect modification was observed, with more pronounced BMD-related acceleration of AVC and MAC progression in older or white participants of one or both sexes, as well as by estimated glomerular filtration rate, though the latter differed by sex for AVC and MAC.

CONCLUSIONS

In this multi-ethnic cohort, low thoracic BMD was significantly, but modestly, associated with increased AVC and MAC progression. This suggests that altered bone mineral metabolism does not have a major impact on calcific valve disease in the general population, but the possibility of a more meaningful influence in higher-risk individuals with osteoporosis will require further investigation.

Management of Ischemic Heart Disease in Pregnancy

PURPOSE OF REVIEW

Cardiovascular disease is an escalating cause of maternal morbidity and mortality. Women are at risk for acute myocardial infarction (MI), and more are living with risk factors for ischemic heart disease (IHD). The purpose of this review is to describe the evaluation and management of women at risk for and diagnosed with IHD in pregnancy.

RECENT FINDINGS

Pregnancy can provoke MI which has been estimated as occurring in 1.5-10/100, 000 deliveries or 1/12,400 hospitalizations, with a high inpatient mortality rate of approximately 5-7%. An invasive strategy may or may not be preferred, but fetal radiation exposure is less of a concern in comparison to maternal mortality. Common medications used to treat IHD may be continued successfully during pregnancy and lactation, including aspirin, which has an emerging role in pregnancy to prevent preeclampsia, preterm labor, and maternal mortality. Hemodynamics can be modulated during pregnancy, labor, and postpartum to mitigate risk for acute decompensation in women with IHD. Cardiologists can successfully manage IHD in pregnancy with obstetric partners and should engage women in a lifetime of cardiovascular care.

Persistence of abnormal global longitudinal strain in women with peripartum cardiomyopathy

OBJECTIVES

Data regarding the longitudinal relationship of global longitudinal strain (GLS) and echocardiographic parameters are lacking in peripartum cardiomyopathy (PPCM). We evaluated GLS and its correlation with change (∆) in left ventricular ejection fraction (LVEF).

METHODS

We retrospectively identified women age ≥16 years hospitalized at Montefiore Medical Center in Bronx, NY from 1999-2015 with International Statistical Classification of Diseases and Related Health Problems, 9th revision codes for PPCM or an occurrence of unexplained heart failure during or up to 5 months postpartum. N = 195 charts were reviewed for inclusion/exclusion criteria, n = 53 patients met criteria for PPCM, and of those, n = 13 had a baseline and follow-up echocardiogram suitable for GLS analysis.

RESULTS

Of those eligible for strain analysis, the mean age was 30 ± 6 years, 46.2% identified as Black and 38.5% as Hispanic/Latina. Baseline LVEF was 30 (25, 35)%, GLS was -13.2 (-14, -7.6)%. At a mean follow-up time of 1.2 ± 0.7 years, 11/13 had persistently mild -15.6 (-16.3, -12.7)%, and 2/13 severely abnormal GLS -7.05 (-7.1, -7.0)%. There was no correlation between baseline GLS and ∆LVEF (r = .014, P = .965).

CONCLUSIONS

Global longitudinal strain is a sensitive method to identify subclinical myocardial dysfunction. In this series of women with PPCM, GLS remained persistently abnormal over time, even if LVEF improved. Future studies should examine the implication of persistently abnormal GLS in PPCM.

SARS-COV-2 infection presenting as ST-elevationmyocardial infarction

We describe a patient presenting with chest discomfort, anterolateral ST elevation, and developing acute cardiogenic shock secondary to SARS-COV-2infection-patient zero presenting to our institution's cardiac catheterization laboratory. The emergent presentation with limited clinical information led to exposure of personnel. The diagnosis was complicated by two negative tests for SARS-COV-2, and high-clinical suspicion from the patient's occupational history led to additional testing in order to confirm the diagnosis.

Surge-in-Place: Conversion of a Cardiac Catheterization Laboratory Into a COVID-19 Intensive Care Unit and Back Again

In Spring 2020, the United States epicenter of COVID-19 was New York City, in which the borough of the Bronx was particularly affected. This Fall, there has been a resurgence of COVID-19 in Europe and the Midwestern United States. We describe our experience transforming our cardiac catheterization laboratories to accommodate an influx of COVID-19 patients so as to provide other hospitals with a potential blueprint. We transformed our pre/postprocedural patient care areas into COVID-19 intensive care and step-down units and maintained emergent invasive care for ST-segment elevation myocardial infarction using existing space and personnel.

Outcomes of ST-elevation myocardial infarction by age and sex in a low-income urban community: The Montefiore STEMI Registry

OBJECTIVES

To compare outcomes by age and sex in race/ethnic minorities presenting with ST-elevation myocardial infarction (STEMI), as studies are limited.

METHODS

We studied sociodemographics, management, and outcomes in 1208 STEMI patients evaluated for primary percutaneous coronary intervention between 2008 and 2014 at Montefiore Health System (Bronx, NY). A majority of patients self-identified as nonwhite, and nearly two-thirds were young (<45 years) or middle-aged (45-64 years).

RESULTS

Risk factors varied significantly across age groups; with more women and non-Hispanic whites, hypertension, diabetes, dyslipidemia, prior cardiovascular disease, non-sinus rhythm, and collagen vascular disease in the older age group (≥65 years); and higher body mass index, smoking, cocaine use, human immunodeficiency virus (HIV) infection and family history of heart disease in the young. Younger women had lower summary socioeconomic scores than younger men. Middle-aged women had more obesity and dysmetabolism, while men had more heavy alcohol use. There was greater disease severity with increasing age; with higher cardiac biomarkers, 3-vessel disease, cardiogenic shock, and coronary artery bypass grafting. Older patients had higher rates of death and death or readmission over 4.3 (interquartile range 2.4, 6.0) years of follow-up. Middle-aged women had higher rates of death or any readmission than men, but these differences were not significant after adjustment.

CONCLUSIONS

These findings indicate a high burden of risk factors in younger adults with STEMI from an inner-city community. Programs to target sociobehavioral factors in disadvantaged settings, including substance abuse, obesity, and risk of HIV, are necessary to more effectively address health disparities in STEMI and its adverse consequences.

Association of human immunodeficiency virus and hepatitis C virus infection with long-term outcomes post-ST segment elevation myocardial infarction in a disadvantaged urban community

BACKGROUND

HIV and HCV have been linked to an increased risk of cardiovascular disease (CVD). Their impact on long-term outcomes following ST-segment myocardial infarction (STEMI) has not been previously studied.

METHODS

We leveraged data from a STEMI registry (n = 1208) at an inner-city health system to assess the influence of HIV and HCV on post-STEMI outcomes. Cox regression was used to compare HIV-monoinfected (n = 22), HCV-monoinfected (n = 26) and HIV-HCV-coinfected patients (n = 8) with the neither-infected group (n = 1152) with regard to death, death or any readmission, and death or CVD readmission.

RESULTS

The cohort was majority black or Hispanic. Median follow-up was 4.3 years. Compared to the neither-infected group, the HIV-monoinfected group showed near-significantly higher risks of death or any readmission (HR = 1.62, 95% CI = 0.96, 2.74) and death or CVD readmission (HR = 1.82, 95% CI = 0.98, 3.39) after full adjustment. On similar comparison, the HCV-monoinfected group exhibited significantly higher risks of death (HR = 2.09, 95% CI = 1.05, 4.15) and death or any readmission (HR = 1.68, 95% CI = 1.07, 2.65), whereas the HIV-HCV-coinfected group showed higher risk of death (HR = 6.51, 95% CI = 2.28, 18.61).

CONCLUSIONS

In this cohort composed mostly of race-ethnic minorities, HIV monoinfection tended to be associated with 1.6-to-1.8-fold higher risk of death or readmission for any cause or CVD over long-term follow-up compared to neither infection, whereas HCV monoinfection was associated with 1.7-to-2.1-fold higher risk of death and death or any readmission, and HIV-HCV coinfection with 6.5-fold higher risk of death. These associations require further study in larger populations, but highlight the importance of identifying and treating HIV and HCV in patients presenting with STEMI.

Lipid mass spectrometry imaging and proteomic analysis of severe aortic stenosis

Severe aortic stenosis (AS) is prevalent in adults ≥ 65 years, a significant cause of morbidity and mortality, with no medical therapy. Lipid and proteomic alterations of human AS tissue were determined using mass spectrometry imaging (MSI) and liquid chromatography electrospray ionization tandem mass spectrometry (LC-ESI-MS/MS) to understand histopathology, potential biomarkers of disease, and progression from non-calcified to calcified phenotype. A reproducible MSI method was developed using healthy murine aortic valves (n = 3) and subsequently applied to human AS (n = 2). Relative lipid levels were spatially mapped and associated with different microdomains. Proteomics for non-calcified and calcified microdomains were performed to ascertain differences in expression. Increased pro-osteogenic and inflammatory lysophosphatidylcholine (LPC) 16:0 and 18:0 were co-localized with calcified microdomains. Proteomics analysis identified differential patterns in calcified microdomains with high LPC and low cholesterol as compared to non-calcified microdomains with low LPC and high cholesterol. Calcified microdomains had higher levels of: apolipoproteins (Apo) B-100 (p < 0.001) and Apo A-IV (p < 0.001), complement C3 and C4-B (p < 0.001), C5 (p = 0.007), C8 beta chain (p = 0.013) and C9 (p = 0.010), antithrombotic proteins alpha-2-macroglobulin (p < 0.0001) and antithrombin III (p = 0.002), and higher anti-calcific fetuin-A (p = 0.02), while the osteoblast differentiating factor transgelin (p < 0.0001), extracellular matrix proteins versican, prolargin, and lumican ( p < 0.001) and regulator protein complement factor H (p < 0.001) were higher in non-calcified microdomains. A combined lipidomic and proteomic approach provided insight into factors potentially contributing to progression from non-calcified to calcific disease in severe AS. Additional studies of these candidates and protein networks could yield new targets for slowing progression of AS.

Impact of the COVID-19 pandemic on interventional cardiology fellowship training in the New York metropolitan area: A perspective from the United States epicenter

Background

The healthcare burden posed by the coronavirus disease 2019 (COVID‐19) pandemic in the New York Metropolitan area has necessitated the postponement of elective procedures resulting in a marked reduction in cardiac catheterization laboratory (CCL) volumes with a potential to impact interventional cardiology (IC) fellowship training.

Methods

We conducted a web‐based survey sent electronically to 21 Accreditation Council for Graduate Medical Education accredited IC fellowship program directors (PDs) and their respective fellows.

Results

Fourteen programs (67%) responded to the survey and all acknowledged a significant decrease in CCL procedural volumes. More than half of the PDs reported part of their CCL being converted to inpatient units and IC fellows being redeployed to COVID‐19 related duties. More than two‐thirds of PDs believed that the COVID‐19 pandemic would have a moderate (57%) or severe (14%) adverse impact on IC fellowship training, and 21% of the PDs expected their current fellows' average percutaneous coronary intervention (PCI) volume to be below 250. Of 25 IC fellow respondents, 95% expressed concern that the pandemic would have a moderate (72%) or severe (24%) adverse impact on their fellowship training, and nearly one‐fourth of fellows reported performing fewer than 250 PCIs as of March 1st. Finally, roughly one‐third of PDs and IC fellows felt that there should be consideration of an extension of fellowship training or a period of early career mentorship after fellowship.

Conclusions

The COVID‐19 pandemic has caused a significant reduction in CCL procedural volumes that is impacting IC fellowship training in the NY metropolitan area. These results should inform professional societies and accreditation bodies to offer tailored opportunities for remediation of affected trainees.

Comparison of Incidence and Outcomes of Cardiogenic Shock Complicating Posterior (Inferior) Versus Anterior ST-Elevation Myocardial Infarction

Cardiogenic shock (CS) is a catastrophic consequence of ST-elevation myocardial infarction (STEMI). CS has been reported to be associated less often with inferior wall (IWMI) than anterior wall STEMI (AWMI). We queried the National Inpatient Sample databases from January 2010 to September 2015 to identify all patients aged ≥18 years admitted with AWMI or IWMI. Patients with a concomitant diagnosis of CS were then identified. Complex samples multivariable logistic regression models were used to compare the incidence, management, and in-hospital mortality of CS complicating IWMI versus AWMI. The incidence of CS was lower in IWMI (9.5%) versus AWMI (14.1%), adjusted OR (aOR) 0.84 (95% confidence interval [CI] 0.81 to 0.87). Revascularization rates with either percutaneous coronary intervention or coronary artery bypass grafting were similar in CS complicating IWMI versus AWMI (80.9% vs 80.3%; aOR 1.05; 95% CI 0.97 to 1.14). The reported use of percutaneous mechanical circulatory support devices was lower in patients with CS-IWMI versus CS-AWMI (44.7% vs 61.0%; aOR 0.55; 95% CI 0.52 to 0.59). In-hospital mortality was modestly lower in patients with CS complicating IWMI versus AWMI (30.3% vs 31.9%; aOR, 0.80; 95% CI 0.75 to 0.86). Use of percutaneous mechanical circulatory support was not associated with lower in-hospital mortality in either CS-AWMI (30.0% vs 34.7; aOR 1.04; 95% CI 0.94 to 1.14) or CS-IWMI (31.0% vs 29.8%; aOR 1.20; 95% CI 1.08 to 1.33). In conclusion, the incidence of CS in the contemporary era is lower in patients with IWMI compared with those with AWMI. CS complicating STEMI is associated with higher in-hospital mortality in AWMI versus IWMI, and outcomes were not different with or without percutaneous circulatory support.

Contemporary Sex-Based Differences by Age in Presenting Characteristics, Use of an Early Invasive Strategy, and Inhospital Mortality in Patients With Non-ST-Segment-Elevation Myocardial Infarction in the United States

BACKGROUND

Prior studies have reported higher inhospital mortality in women versus men with non-ST-segment-elevation myocardial infarction. Whether this is because of worse baseline risk profile compared with men or sex-based disparities in treatment is not completely understood.

METHODS AND RESULTS

We queried the 2003 to 2014 National Inpatient Sample databases to identify all hospitalizations in patients aged ≥18 years with the principal diagnosis of non-ST-segment-elevation myocardial infarction. Complex samples multivariable logistic regression models were used to examine sex differences in use of an early invasive strategy and inhospital mortality. Of 4 765 739 patients with non-ST-segment-elevation myocardial infarction, 2 026 285 (42.5%) were women. Women were on average 6 years older than men and had a higher comorbidity burden. Women were less likely to be treated with an early invasive strategy (29.4% versus 39.2%; adjusted odds ratio, 0.92; 95% confidence interval, 0.91-0.94). Women had higher crude inhospital mortality than men (4.7% versus 3.9%; unadjusted odds ratio, 1.22; 95% confidence interval, 1.20-1.25). After adjustment for age (adjusted odds ratio, 0.96; 95% confidence interval, 0.94-0.98) and additionally for comorbidities, other demographics, and hospital characteristics, women had 10% lower odds of inhospital mortality (adjusted odds ratio, 0.90; 95% confidence interval, 0.89-0.92). Further adjustment for differences in the use of an early invasive strategy did not change the association between female sex and lower risk-adjusted inhospital mortality.

CONCLUSIONS

Although women were less likely to be treated with an early invasive strategy compared with men, the lower use of an early invasive strategy was not responsible for the higher crude inhospital mortality in women, which could be entirely explained by older age and higher comorbidity burden.

Biomarkers of mineral metabolism and progression of aortic valve and mitral annular calcification: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND AIMS

Previous research has implicated dysregulation of phosphate metabolism and calcium-phosphate solubilization in cardiovascular calcification, but epidemiologic studies evaluating longitudinal associations with valvular or annular calcification by computed tomography (CT), a highly sensitive imaging modality, are lacking. Our primary aim was to investigate the associations of mineral biomarkers with incidence and progression of aortic valve calcification (AVC) and mitral annular calcification (MAC).

METHODS

We evaluated the associations of serum FGF-23 (n = 6547 participants), phosphate (n = 6547), and fetuin-A (n = 2550) measured at baseline in the community-based Multi-Ethnic Study of Atherosclerosis with AVC and MAC on CT performed at baseline and at a median of 2.4 (1.6, 3.1) years later. We used linear mixed-effects models to account simultaneously for prevalence, incidence and progression of AVC and MAC.

RESULTS

After adjustment for demographic and clinical characteristics, a significant association was documented for FGF-23 with accelerated annual progression of MAC (2.83 Agatston units (AU), 95% CI = 0.49, 5.17 AU, per standard deviation (18.46 pg/mL) of FGF-23), but this was not seen for phosphate or fetuin-A. None of these biomarkers was associated with accelerated annual progression of AVC.

CONCLUSIONS

This study provides evidence relating serum FGF-23 to accelerated annual MAC progression. Whether this mineral regulator is a risk marker or is involved in pathogenesis merits further investigation.

Addressing maternal mortality: the pregnant cardiac patient

Cardiac disease in pregnancy is the number one indirect cause of maternal mortality in the United States. We propose a triad solution that includes universal screening for cardiovascular disease in pregnancy and postpartum women, patient education, and institution of a multidisciplinary cardiac team. Additionally, we emphasize essential elements to maximize care for the pregnant cardiac patient based on our experience at our institution in Bronx, NY.

Relationship of Hospital Teaching Status with In-Hospital Outcomes for ST-Segment Elevation Myocardial Infarction

BACKGROUND

Prior analyses have largely shown a survival advantage with admission to a teaching hospital for acute myocardial infarction. However, most prior studies report data on patients hospitalized over a decade ago. It is important to re-examine the association of hospital teaching status with outcomes of acute myocardial infarction in the current era.

METHODS

We queried the 2010 to 2014 National Inpatient Sample databases to identify all patients aged ≥18 years hospitalized with the principal diagnosis of ST-segment elevation myocardial infarction (STEMI). Multivariable logistic regression models were constructed to compare rates of reperfusion and in-hospital outcomes between patients admitted to teaching vs nonteaching hospitals.

RESULTS

Of 546,252 patients with STEMI, 273,990 (50.1%) were admitted to teaching hospitals. Compared with patients admitted to nonteaching hospitals, those at teaching hospitals were more likely to receive reperfusion therapy during the hospitalization (86.7% vs 81.5%; adjusted odds ratio [OR] 1.41; 95% confidence interval [CI], 1.39-1.44; P < .001) and had lower risk-adjusted in-hospital mortality (4.9% vs 6.9%; adjusted OR 0.84; 95% CI, 0.82-0.86; P < .001). After further adjustment for differences in use of in-hospital reperfusion therapy, the association of teaching hospital status with lower risk-adjusted in-hospital mortality was significantly attenuated but remained statistically significant (adjusted OR 0.97; 95% CI, 0.94-0.99; P = .02).

CONCLUSIONS

Patients admitted to teaching hospitals are more likely to receive reperfusion and have lower risk-adjusted in-hospital mortality after STEMI compared with those admitted to nonteaching hospitals. Our results suggest that hospital performance for STEMI continues to be better at teaching hospitals in the contemporary era.

Relationship of bone mineral density with valvular and annular calcification in community-dwelling older people: The Cardiovascular Health Study

Associations between bone mineral density and aortic valvular, aortic annular, and mitral annular calcification were investigated in a cross-sectional analysis of a population-based cohort of 1497 older adults. Although there was no association between continuous bone mineral density and outcomes, a significant association between osteoporosis and aortic valvular calcification in men was found.

INTRODUCTION

The process of cardiac calcification bears a resemblance to skeletal bone metabolism and its regulation. Experimental studies suggest that bone mineral density (BMD) and valvular calcification may be reciprocally related, but epidemiologic data are sparse.

METHODS

We tested the hypothesis that BMD of the total hip and femoral neck measured by dual-energy X-ray absorptiometry (DXA) is inversely associated with prevalence of three echocardiographic measures of cardiac calcification in a cross-sectional analysis of 1497 older adults from the Cardiovascular Health Study. The adjusted association of BMD with aortic valve calcification (AVC), aortic annular calcification (AAC), and mitral annular calcification (MAC) was assessed with relative risk (RR) regression.

RESULTS

Mean (SD) age was 76.2 (4.8) years; 58% were women. Cardiac calcification was highly prevalent in women and men: AVC, 59.5 and 71.0%; AAC 45.1 and 46.7%; MAC 42.8 and 39.5%, respectively. After limited and full adjustment for potential confounders, no statistically significant associations were detected between continuous BMD at either site and the three measures of calcification. Assessment of WHO BMD categories revealed a significant association between osteoporosis at the total hip and AVC in men (adjusted RR compared with normal BMD = 1.24 (1.01-1.53)). In graded sensitivity analyses, there were apparent inverse associations between femoral neck BMD and AVC with stenosis in men, and femoral neck BMD and moderate/severe MAC in women, but these were not significant.

CONCLUSION

These findings support further investigation of the sex-specific relationships between low BMD and cardiac calcification, and whether processes linking the two could be targeted for therapeutic ends.

Regional Variation in Utilization, In-hospital Mortality, and Health-Care Resource Use of Transcatheter Aortic Valve Implantation in the United States

We queried the National Inpatient Sample database from 2012 to 2014 to identify all patients aged ≥18 years undergoing transcatheter aortic valve implantation (TAVI) in the United States. Regional differences in TAVI utilization, in-hospital mortality, and health-care resource use were analyzed. Of 41,025 TAVI procedures in the United States between 2012 and 2014, 10,390 were performed in the Northeast, 9,090 in the Midwest, 14,095 in the South, and 7,450 in the West. Overall, the number of TAVI implants per million adults increased from 24.8 in 2012 to 63.2 in 2014. The utilization of TAVI increased during the study period in all 4 geographic regions, with the number of implants per million adults being highest in the Northeast, followed by the Midwest, South, and West, respectively. Overall in-hospital mortality was 4.2%. Compared with the Northeast, risk-adjusted in-hospital mortality was higher in the Midwest (adjusted odds ratio [aOR] 1.26 [1.07 to 1.48]) and the South (aOR 1.61 [1.40 to 1.85]) and similar in the West (aOR 1.00 [0.84 to 1.18]). Average length of stay was shorter in all other regions compared with the Northeast. Among patients surviving to discharge, disposition to a skilled nursing facility or home health care was most common in the Northeast, whereas home discharge was most common in the West. Average hospital costs were highest in the West. In conclusion, we observed significant regional differences in TAVI utilization, in-hospital mortality, and health-care resource use in the United States. The findings of our study may have important policy implications and should provide an impetus to understand the source of this regional variation.

Relation of Serum Vitamin D to Risk of Mitral Annular and Aortic Valve Calcium (from the Multi-Ethnic Study of Atherosclerosis)

Serum 25-hydroxyvitamin D [25(OH)D] concentration has been identified as a possible modifiable risk factor for cardiovascular disease (CVD). We hypothesized that serum 25(OH)D concentration would be associated with calcifications of the left-sided heart valves, which are markers of CVD risk. Aortic valve calcium (AVC) and mitral annular calcium (MAC) were quantified from cardiac computed tomography scans performed on 5,530 Multi-Ethnic Study of Atherosclerosis participants at the baseline examination (2000 to 2002) and at a follow-up visit at either Examination 2 (2002 to 2004) or Examination 3 (2004 to 2005). 25(OH)D was measured from serum samples collected at the baseline examination. Using relative risk regression, we evaluated the multivariable-adjusted risk of prevalent and incident AVC and MAC in this ethnically diverse population free of clinical CVD at baseline. The mean age of participants was 62 ± 10 years; 53% were women, 40% white, 26% black, 21% Hispanic, and 12% Chinese. Prevalent AVC and MAC were observed in 12% and 9% of study sample, respectively. There were no significant associations between 25(OH)D and prevalent AVC or MAC. Over a mean follow-up of 2.5 years, 4% developed incident AVC and 5% developed incident MAC. After adjusting for demographic variables, each 10 ng/ml higher serum 25(OH)D was associated with a 15% (relative risk 0.85, 95% confidence interval 0.74 to 0.98) lower risk of incident MAC but not AVC. However, this association was no longer significant after adjusting for lifestyle and CVD risk factors. Results suggest a possible link between serum 25(OH)D and the risk for incident MAC, but future studies with longer follow-up are needed to further test this association.

Outcomes of ≤6-month versus 12-month dual antiplatelet therapy after drug-eluting stent implantation: A meta-analysis and meta-regression

BACKGROUND

The benefit of ≤6-month compared with 12-month dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) placement remains controversial. We performed a meta-analysis and meta-regression of ≤6-month versus 12-month DAPT in patients undergoing PCI with DES placement.

METHODS

We conducted electronic database searches of randomized controlled trials (RCTs) comparing DAPT durations after DES placement. For studies with longer follow-up, outcomes at 12 months were identified. Odds ratios and 95% confidence intervals were computed with the Mantel-Haenszel method. Fixed-effect models were used; if heterogeneity (I) > 40 was identified, effects were obtained with random models.

RESULTS

Nine RCTs were included with total n = 19,224 patients. No significant differences were observed between ≤6-month compared with 12-month DAPT in all-cause mortality (OR 0.87; 95% confidence interval (CI): 0.69-1.11), cardiovascular (CV) mortality (OR 0.89; 95% CI: 0.66-1.21), non-CV mortality (OR 0.85; 95% 0.58-1.24), myocardial infarction (OR 1.10; 95% CI: 0.89-1.37), stroke (OR 0.97; 95% CI: 0.67-1.42), stent thrombosis (ST) (OR 1.37; 95% CI: 0.89-2.10), and target vessel revascularization (OR 0.95; 95% CI: 0.77-1.18). No significant difference in major bleeding (OR 0.72; 95% CI: 0.49-1.05) was observed, though the all-bleeding event rate was significantly lower in the ≤6-month DAPT group (OR 0.76; 95% CI: 0.59-0.96). In the meta-regression analysis, a significant association between bleeding events and non-CV mortality with 12-month DAPT was found, as well as between ST and mortality in addition to MI with ≤6-month DAPT.

CONCLUSION

DAPT for ≤6 months is associated with similar mortality and ischemic outcomes but less bleeding events compared with 12-month DAPT after PCI with DES.

Association of inflammatory, lipid and mineral markers with cardiac calcification in older adults

OBJECTIVE

Calcification of the aortic valve and adjacent structures involves inflammatory, lipid and mineral metabolism pathways. We hypothesised that circulating biomarkers reflecting these pathways are associated with cardiac calcification in older adults.

METHODS

We investigated the associations of various biomarkers with valvular and annular calcification in the Cardiovascular Health Study. Of the 5888 participants, up to 3585 were eligible after exclusions for missing biomarker, covariate or echocardiographic data. We evaluated analytes reflecting lipid (lipoprotein (Lp) (a), Lp-associated phospholipase A₂ (LpPLA₂) mass and activity), inflammatory (interleukin-6, soluble (s) CD14) and mineral metabolism (fetuin-A, fibroblast growth factor (FGF)-23) pathways that were measured within 5 years of echocardiography. The relationships of plasma biomarkers with aortic valve calcification (AVC), aortic annular calcification (AAC) and mitral annular calcification (MAC) were assessed with relative risk (RR) regression.

RESULTS

Calcification was prevalent: AVC 59%, AAC 45% and MAC 41%. After adjustment, Lp(a), LpPLA₂ mass and activity and sCD14 were positively associated with AVC. RRs for AVC per SD (95% CI) were as follows: Lp(a), 1.051 (1.022 to 1.081); LpPLA₂ mass, 1.036 (1.006 to 1.066) and LpPLA₂ activity, 1.037 (1.004 to 1.071); sCD14, 1.039 (1.005 to 1.073). FGF-23 was positively associated with MAC, 1.040 (1.004 to 1.078) and fetuin-A was negatively associated, 0.949 (0.911 to 0.989). No biomarkers were significantly associated with AAC.

CONCLUSION

This study shows novel associations of circulating FGF-23 and fetuin-A with MAC, and LpPLA₂ and sCD14 with AVC, confirming that previously reported for Lp(a). Further investigation of Lp and inflammatory pathways may provide added insight into the aetiology of AVC, while study of phosphate regulation may illuminate the pathogenesis of MAC.

Five-year follow-up of patients treated for coronary artery disease in the face of an increasing burden of co-morbidity and disease complexity (from the NHLBI Dynamic Registry)

Management of coronary artery disease (CAD) has evolved over the past decade, but there are few prospective studies evaluating long-term outcomes in a real-world setting of evolving technical approaches and secondary prevention. The aim of this study was to determine how the mortality and morbidity of CAD has changed in patients who have undergone percutaneous coronary intervention (PCI), in the setting of co-morbidities and evolving management. The National Heart, Lung, and Blood Institute Dynamic Registry was a cohort study of patients undergoing PCI at various time points. Cohorts were enrolled in 1999 (cohort 2, n = 2,105), 2004 (cohort 4, n = 2,112), and 2006 (cohort 5, n = 2,176), and each was followed out to 5 years. Primary outcomes were death, myocardial infarction (MI), coronary artery bypass grafting, repeat PCI, and repeat revascularization. Secondary outcomes were PCI for new obstructive lesions at 5 years, 5-year rates of death and MI stratified by the severity of coronary artery and co-morbid disease. Over time, patients were more likely to have multiple co-morbidities and more severe CAD. Despite greater disease severity, there was no significant difference in death (16.5% vs 17.6%, adjusted hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.74 to 1.08), MI (11.0% vs 10.6%, adjusted HR 0.87, 95% CI 0.70 to 1.08), or repeat PCI (20.4% vs 22.2%, adjusted HR 0.98, 95% CI 0.85 to 1.17) at 5-year follow-up, but there was a significant decrease in coronary artery bypass grafting (9.1% vs 4.3%, adjusted HR 0.44, 95% CI 0.32 to 0.59). Patients with 5 co-morbidities had a 40% to 60% death rate at 5 years. There was a modestly high rate of repeat PCI for new lesions, indicating a potential failure of secondary prevention for this population in the face of increasing co-morbidity. Overall 5-year rates of death, MI, repeat PCI, and repeat PCI for new lesions did not change significantly in the context of increased co-morbidities and complex disease.

In comparison to the myocardial perfusion scintigraphy, a treadmill stress test is a viable, efficient and cost effective option to predict cardiovascular events in elderly patients

OBJECTIVE

To define the prognostic value and cost-effectiveness of the treadmill stress test (TST) in comparison to the dipyridamole myocardial perfusion scintigraphy (DIP), in individuals > or = 75 years of age.

METHODS

Consecutive and prospective assessment of 66 patients (40% male) aged 81 +/- 5 years of which 57% were hypertensive, 38% had dyslipidemia and 28% were diabetics. The Bruce protocol was adapted for a tilt treadmill and the TST prognostic value was obtained using the Duke treadmill score.

RESULTS

The TST duration, recommended maximum heart rate percentage and double product at peak exercise were respectively: 7 +/- 3 minutes, 95 +/- 9% and 24,946 +/- 4,576 (bpm x mmHg). The TST and DIP presented similar positive results for myocardial ischemia (21% vs 15%, respectively). The correlation between the tests was 88% (Kappa 0.63, p<0.01). During 685 +/- 120 days of follow-up, nine major events occurred: 6 deaths, 2 acute coronary syndromes and 1 myocardial revascularization. The variables associated with the major events were: age (83 +/- 6 vs 80 +/- 4 years; p=0.048), male gender (78% vs 33%; p=0.02), ST segment depression (1 +/- 1 mm vs 0.25 +/- 0.6 mm; p= 0.01), high or intermediate risk determined by the Duke treadmill score - combined in one group (44% vs 2%; p=0.001) and abnormal DIP (44% vs 10%, p= 0.02).

CONCLUSION

For this elderly population, the TST was an efficient and viable option with a similar diagnostic value in comparison to the DIP. However, the TST was more accurate in the prediction of major events and offers a lower cost.

Impaired ATP-binding cassette transporter A1-mediated sterol efflux from oxidized LDL-loaded macrophages

We investigated the interaction of oxidized low density lipoprotein (OxLDL) with the ATP-binding cassette A1 (ABCA1) pathway in J774 macrophages. Cellular efflux to apolipoprotein AI (apo-AI) of OxLDL-derived cholesterol was lower than efflux of cholesterol derived from acetylated low density lipoprotein (AcLDL). ABCA1 upregulation by 8-(4-chlorophenylthio)adenosine 3':5'-cyclic monophosphate (cpt-cAMP) or 22 (R)-hydroxycholesterol (22-OH) and 9-cis retinoic acid (9cRA) increased the efflux to apo-AI of cellular sterols derived from AcLDL, but not of those from OxLDL. AcLDL, but not OxLDL, induced ABCA1 protein content and activity in J774. However, OxLDL did not influence J774 ABCA1 upregulation by cpt-cAMP or 22-OH/9cRA. We conclude that sterols released to cells by OxLDL are available neither as substrate nor as modulator of ABCA1.