Early Assessment of Cardiac Allograft Vasculopathy Risk Among Recipients of Hepatitis C Virus-infected Donors in the Current Era

BACKGROUND

Transplantation of hearts from hepatitis C virus (HCV)-positive donors has increased substantially in recent years following development of highly effective direct-acting antiviral therapies for treatment and cure of HCV. Although historical data from the pre-direct-acting antiviral era demonstrated an association between HCV-positive donors and accelerated cardiac allograft vasculopathy (CAV) in recipients, the relationship between the use of HCV nucleic acid test-positive (NAT+) donors and the development of CAV in the direct-acting antiviral era remains unclear.

METHODS AND RESULTS

We performed a retrospective, single-center observational study comparing coronary angiographic CAV outcomes during the first year after transplant in 84 heart transplant recipients of HCV NAT+ donors and 231 recipients of HCV NAT- donors. Additionally, in a subsample of 149 patients (including 55 in the NAT+ cohort and 94 in the NAT- cohort) who had serial adjunctive intravascular ultrasound examination performed, we compared development of rapidly progressive CAV, defined as an increase in maximal intimal thickening of ≥0.5 mm in matched vessel segments during the first year post-transplant. In an unadjusted analysis, recipients of HCV NAT+ hearts had reduced survival free of CAV ≥1 over the first year after heart transplant compared with recipients of HCV NAT- hearts. After adjustment for known CAV risk factors, however, there was no significant difference between cohorts in the likelihood of the primary outcome, nor was there a difference in development of rapidly progressive CAV.

CONCLUSIONS

These findings support larger, longer-term follow-up studies to better elucidate CAV outcomes in recipients of HCV NAT+ hearts and to inform post-transplant management strategies.

Extracorporeal Life Support for Cardiogenic Shock in Adult Congenital Heart Disease-An ELSO Registry Analysis

There are minimal data on the use of venoarterial extracorporeal membrane life support (VA-ECLS) in adult congenital heart disease (ACHD) patients presenting with cardiogenic shock (CS). This study sought to describe the population of ACHD patients with CS who received VA-ECLS in the Extracorporeal Life Support Organization (ELSO) Registry. This was a retrospective analysis of adult patients with diagnoses of ACHD and CS in ELSO from 2009-2021. Anatomic complexity was categorized using the American College of Cardiology/American Heart Association 2018 guidelines. We described patient characteristics, complications, and outcomes, as well as trends in mortality and VA-ECLS utilization. Of 528 patients who met inclusion criteria, there were 32 patients with high-complexity anatomy, 196 with moderate-complexity anatomy, and 300 with low-complexity anatomy. The median age was 59.6 years (interquartile range, 45.8-68.2). The number of VA-ECLS implants increased from five implants in 2010 to 81 implants in 2021. Overall mortality was 58.3% and decreased year-by-year (β= -2.03 [95% confidence interval, -3.36 to -0.70], p = 0.007). Six patients (1.1%) were bridged to heart transplantation and 21 (4.0%) to durable ventricular assist device. Complications included cardiac arrhythmia/tamponade (21.6%), surgical site bleeding (17.6%), cannula site bleeding (11.4%), limb ischemia (7.4%), and stroke (8.7%). Utilization of VA-ECLS for CS in ACHD patients has increased over time with a trend toward improvement in survival to discharge.

Design and characteristics of the prophylactic intra-operative ventricular arrhythmia ablation in high-risk LVAD candidates (PIVATAL) trial

BACKGROUND

The use of a Left Ventricular Assist Device (LVAD) in patients with advanced heart failure refractory to optimal medical management has progressed steadily over the past two decades. Data have demonstrated reduced LVAD efficacy, worse clinical outcome, and higher mortality for patients who experience significant ventricular tachyarrhythmia (VTA). We hypothesize that a novel prophylactic intra-operative VTA ablation protocol at the time of LVAD implantation may reduce the recurrent VTA and adverse events postimplant.

METHODS

We designed a prospective, multicenter, open-label, randomized-controlled clinical trial enrolling 100 patients who are LVAD candidates with a history of VTA in the previous 5 years. Enrolled patients will be randomized in a 1:1 fashion to intra-operative VTA ablation (n = 50) versus conventional medical management (n = 50) with LVAD implant. Arrhythmia outcomes data will be captured by an implantable cardioverter defibrillator (ICD) to monitor VTA events, with a uniform ICD programming protocol. Patients will be followed prospectively over a mean of 18 months (with a minimum of 9 months) after LVAD implantation to evaluate recurrent VTA, adverse events, and procedural outcomes. Secondary endpoints include right heart function/hemodynamics, healthcare utilization, and quality of life.

CONCLUSION

The primary aim of this first-ever randomized trial is to assess the efficacy of intra-operative ablation during LVAD surgery in reducing VTA recurrence and improving clinical outcomes for patients with a history of VTA.

Ventricular Remodeling and Outcomes After Mitral Transcatheter Edge-to-Edge Repair in Heart Failure: The COAPT Trial

BACKGROUND

The relationship between left ventricular (LV) remodeling and clinical outcomes after treatment of severe mitral regurgitation (MR) in heart failure (HF) has not been examined.

OBJECTIVES

The aim of this study was to evaluate the association between LV reverse remodeling and subsequent outcomes and assess whether transcatheter edge-to-edge repair (TEER) and residual MR are associated with LV remodeling in the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial.

METHODS

Patients with HF and severe MR who remained symptomatic on guideline-directed medical therapy (GDMT) were randomized to TEER plus GDMT or GDMT alone. Baseline and 6-month core laboratory measurements of LV end-diastolic volume index and LV end-systolic volume index were examined. Change in LV volumes from baseline to 6 months and clinical outcomes from 6 months to 2 years were evaluated using multivariable regression.

RESULTS

The analytical cohort comprised 348 patients (190 treated with TEER, 158 treated with GDMT alone). A decrease in LV end-diastolic volume index at 6 months was associated with reduced cardiovascular death between 6 months and 2 years (adjusted HR: 0.90 per 10 mL/m² decrease; 95% CI: 0.81-1.00; P = 0.04), with consistent results in both treatment groups (P_interaction = 0.26). Directionally similar but nonsignificant relationships were present for all-cause death and HF hospitalization and between reduced LV end-systolic volume index and all outcomes. Neither treatment group nor MR severity at 30 days was associated with LV remodeling at 6 or 12 months. The treatment benefits of TEER were not significant regardless of the degree of LV remodeling at 6 months.

CONCLUSIONS

In patients with HF and severe MR, LV reverse remodeling at 6 months was associated with subsequently improved 2-year outcomes but was not affected by TEER or the extent of residual MR. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial] and COAPT CAS [COAPT]; NCT01626079).

Guideline-Directed Medical Therapy Tolerability in Patients With Heart Failure and Mitral Regurgitation: The COAPT Trial

BACKGROUND

In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial, a central committee of heart failure (HF) specialists optimized guideline-directed medical therapies (GDMT) and documented medication and goal dose intolerances before patient enrollment.

OBJECTIVES

The authors sought to assess the rates, reasons, and predictors of GDMT intolerance in the COAPT trial.

METHODS

Baseline use, dose, and intolerances of angiotensin-converting enzyme inhibitors (ACEIs) angiotensin II receptor blockers (ARBs), angiotensin receptor neprilysin inhibitors (ARNIs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs) were analyzed in patients with left ventricular ejection fraction (LVEF) ≤40%, in whom maximally tolerated doses of these agents as assessed by an independent HF specialist were required before enrollment.

RESULTS

A total of 464 patients had LVEF ≤40% and complete medication information. At baseline, 38.8%, 39.4%, and 19.8% of patients tolerated 3, 2, and 1 GDMT classes, respectively (any dose); only 1.9% could not tolerate any GDMT. Beta-blockers were the most frequently tolerated GDMT (93.1%), followed by ACEIs/ARBs/ARNIs (68.5%), and then MRAs (55.0%). Intolerances differed by GDMT class, but hypotension and kidney dysfunction were most common. Goal doses were uncommonly achieved for beta-blockers (32.3%) and ACEIs/ARBs/ARNIs (10.2%) due to intolerances limiting titration. Only 2.2% of patients tolerated goal doses of all 3 GDMT classes.

CONCLUSIONS

In a contemporary trial population with HF, severe mitral regurgitation, and systematic HF specialist-directed GDMT optimization, most patients had medical intolerances prohibiting 1 or more GDMT classes and achieving goal doses. The specific intolerances noted and methods used for GDMT optimization provide important lessons for the implementation of GDMT optimization in future clinical trials. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial] [COAPT]; NCT01626079).

Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement Outcomes in Left Ventricular Assist Device Patients with Aortic Insufficiency

Background: Worsening aortic insufficiency (AI) is a known sequela of prolonged continuous-flow left ventricular assist device (LVAD) support with a significant impact on patient outcomes. While medical treatment may relieve symptoms, it is unlikely to halt progression. Surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) are among non-medical interventions available to address post-LVAD AI. Limited data are available on outcomes with either SAVR or TAVR for the management of post-LVAD AI. Methods: The National Inpatient Sample data collected for hospital admissions between the years 2015 and 2018 for patients with pre-existing continuous-flow LVAD undergoing TAVR or SAVR for AI were queried. The primary outcome of interest was a composite of in-hospital mortality, stroke, transient ischaemic attack, MI, pacemaker implantation, need for open aortic valve surgery, vascular complications and cardiac tamponade. Results: Patients undergoing TAVR were more likely to receive their procedure during an elective admission (57.1 versus 30%, p=0.002), and a significantly higher prevalence of comorbidities, as assessed by the Elixhauser Comorbidity Index, was observed in the SAVR group (29 versus 18; p=0.0001). We observed a significantly higher prevalence of the primary composite outcome in patients undergoing SAVR (30%) compared with TAVR (14.3%; p=0.001). Upon multivariable analysis adjusting for the type of admission and Elixhauser Comorbidity Index, TAVR was associated with significantly lower odds of the composite outcome (odds ratio 0.243; 95% CI [0.06-0.97]; p=0.045). Conclusion: In this nationally representative cohort of LVAD patients with post-implant AI, it was observed that TAVR was associated with a lower risk of adverse short-term outcomes compared with SAVR.

Early Blood Pressure Variables Associated With Improved Outcomes in VA-ECLS: The ELSO Registry Analysis

BACKGROUND

As utilization of veno-arterial extracorporeal life support (VA-ECLS) in treatment of cardiogenic shock (CS) continues to expand, clinical variables that guide clinicians in early recognition of myocardial recovery and therefore, improved survival, after VA-ECLS are critical. There remains a paucity of literature on early postinitiation blood pressure measurements that predict improved outcomes.

OBJECTIVES

The objective of this study is to help identify early blood pressure variables associated with improved outcomes in VA-ECLS.

METHODS

The authors queried the ELSO (Extracorporeal Life Support Organization) registry for cardiogenic shock patients treated with VA-ECLS or venovenous arterial ECLS between 2009 and 2020. Their inclusion criteria included treatment with VA-ECLS or venovenous arterial ECLS; absence of pre-existing durable right, left, or biventricular assist devices; no pre-ECLS cardiac arrest; and no surgical or percutaneously placed left ventricular venting devices during their ECLS runs. Their primary outcome of interest was the survival to discharge during index hospitalization.

RESULTS

A total of 2,400 CS patients met the authors' inclusion criteria and had complete documentation of blood pressures. Actual mortality during index hospitalization in their cohort was 49.5% and survivors were younger and more likely to be Caucasian, intubated for >30 hours pre-ECLS initiation, and had a favorable baseline SAVE (Survival After Veno-arterial ECMO) score (P < 0.05 for all). Multivariable regression analyses adjusting for SAVE score, age, ECLS flow at 4 hours, and race showed that every 10-mm Hg increase in baseline systolic blood pressure (HR: 0.92 [95% CI: 0.89-0.95]; P < 0.001), and baseline pulse pressure (HR: 0.88 [95% CI: 0.84-0.91]; P < 0.001) at 24 hours was associated with a statistically significant reduction in mortality.

CONCLUSIONS

Early (within 24 hours) improvements in pulse pressure and systolic blood pressure from baseline are associated with improved survival to discharge among CS patients treated with VA-ECLS.

Impact of increased donor distances following adult heart allocation system changes: A single center review of 1-year outcomes

BACKGROUND

On October 18, 2018, several changes to the donor heart allocation system were enacted. We hypothesize that patients undergoing orthotopic heart transplantation (OHT) under the new allocation system will see an increase in ischemic times, rates of primary graft dysfunction, and 1-year mortality due to these changes.

METHODS

In this single-center retrospective study, we reviewed the charts of all OHT patients from October 2017 through October 2019. Pre- and postallocation recipient demographics were compared. Survival analysis was performed using the Kaplan-Meier method.

RESULTS

A total of 184 patients underwent OHT. Recipient demographics were similar between cohorts. The average distance from donor increased by more than 150 km (p = .006). Patients in the postallocation change cohort demonstrated a significant increase in the rate of severe left ventricle primary graft dysfunction from 5.4% to 18.7% (p = .005). There were no statistically significant differences in 30-day mortality or 1-year survival. Time on the waitlist was reduced from 203.8 to 103.7 days (p = .006).

CONCLUSIONS

Changes in heart allocation resulted in shorter waitlist times at the expense of longer donor distances and ischemic times, with an associated negative impact on early post-transplantation outcomes. No significant differences in 30-day or 1-year mortality were observed.

CardioMEMS Implantation Using Gadolinium-based Contrast Agent: A Case Report

A 57-year-old woman with New York Heart Association Class III heart failure requiring multiple hospitalisations over the previous year presented for CardioMEMS implantation. Because of the patient’s allergy history of anaphylaxis to iodine-based contrast agent she underwent the device implantation with gadolinium-based contrast agent (Magnevist), which was successful.

No survival benefit associated with waiting for non-lung donor heart transplants for adult recipients with congenital heart disease

BACKGROUND

Adults with congenital heart disease (CHD) awaiting heart transplant (HT) have higher mortality and waitlist removal due to clinical deterioration than those without CHD. The selective use of non-lung donors (NLD) to recover donor pulmonary vasculature to assist in graft implantation may be a contributing factor and is supported by consensus statements despite the recent use of pericardium or graft material as an alternative in pulmonary vascular reconstruction. The impact of selecting NLD for CHD recipients on wait time and mortality has not been evaluated.

METHODS/RESULTS

In the United Network for Organ Sharing (UNOS) Registry, 1271 HT recipients age ≥ 18 with CHD were identified between 1987 and 2016, 68% of which had NLDs. Prior to HT, NLD recipients were significantly less likely to be listed UNOS Status 1A, require mechanical ventilation, or intra-aortic balloon pump support. There was no difference in mean waitlist time (254 vs. 278 days, p = .31), 1-year mortality (82% vs. 80%, p = .81; adjusted odds ratio 1.32, 95% confidence interval [CI] 0.96-1.83, p = .08), or overall mortality (adjusted hazard ratio 1.08, 95% CI 0.86-1.36, p = .48) between recipients from NLD and concomitant lung donors.

CONCLUSIONS

Adult CHD patients who are less critically ill or listed at a lower status are more likely to receive HT from NLD. There is no overall mortality benefit associated with this practice. While specific cases may necessitate waiting for NLD, programs need to re-evaluate whether this should remain a more widespread practice among CHD patients.

HeartMate 3 in a ccTGA patient

A 49-year-old female with congenitally corrected (or levo-) transposition of the great arteries complicated by nonischemic cardiomyopathy presented for worsening heart failure despite guideline-directed medical therapy and was found to be in cardiogenic shock. She successfully underwent ventricular assist device placement with a HeartMate III to her systemic right ventricle as a bridge to transplantation.

Correction to: Vitamin D and Heart Failure

The original version of this article, published in Current Heart Failure Reports, Volume 14, Issue 5, October 2017, erroneously cited an author's name as Marshall Brinkley, D" when it should be "Brinkley, DM."

Association of cystatin C with measures of obesity and its impact on cardiovascular events among healthy US adults

BACKGROUND

This study sought to explore the relationship between cystatin C (CysC) and anthropometric measures of obesity and the influence of this association on mortality [cardiovascular disease (CVD), coronary heart disease, and all-cause] in a nationally representative population free of CVD, diabetes mellitus, and macroalbuminuria (MA).

METHODS

The study cohort included 4577 adult participants of the Third National Health and Nutrition Examination Survey (NHANES). Spearman correlation analysis was performed to ascertain the association between various anthropometric measures and CysC. Formal statistical analyses of the interaction term between anthropometric measures and CysC for outcomes were performed followed by stratified multivariate Cox proportional hazard analyses.

RESULTS

A moderate degree of association was seen between CysC and measures of visceral adiposity as represented by waist-to-height ratio (WHR) and waist circumference (WC) and only a weak association between CysC and body mass index (BMI). CysC was predictive of all study outcomes in individuals with normal anthropometric measurements only.

CONCLUSIONS

CysC correlated better with measures of visceral adiposity (WC and WHR) compared to BMI and appears to be a better predictor of adverse cardiovascular outcomes among those with anthropometric measures not suggestive of obesity compared to those with abnormal measures of anthropometry.

Non-high-density lipoprotein cholesterol and coronary artery calcium progression in a multiethnic US population

Non-high-density lipoprotein cholesterol (non-HDLc) is an independent predictor of cardiovascular disease risk, with elevated levels signifying an increased risk beyond low-density lipoprotein. Previous data have shown inconsistent association of lipid subfractions with progression of coronary artery calcium (CAC), a surrogate marker of incident cardiovascular disease. We sought to evaluate the association between non-HDLc and development (incident) and progression of CAC in a cohort of multiethnic asymptomatic subjects. The cohort (n = 5,705) was derived from the limited access data set of the Multi-Ethnic Study of Atherosclerosis obtained from the National Heart Lung and Blood Institute. Multivariable regression analysis was performed to derive the association between non-HDLc and incident CAC (n = 2,927) and non-HDLc and progression of CAC (n = 2,778). In the population without CAC at baseline, non-HDLc, especially >190 mg/dl, was independently associated with incident CAC (relative risk 1.40, 95% confidence interval 1.09 to 1.79, p = 0.008) after adjustments with age, gender, race, systolic blood pressure, antihypertension medication use, smoking, diabetes, lipid-lowering therapy use, follow-up duration, and waist-hip ratio. Similarly, among those with CAC at baseline, non-HDLc levels >190 mg/dl were associated with significant CAC progression in the overall population (β 16.4, 95% confidence interval -5.63 to 27.2, p = 0.003) after adjustments. In conclusion, non-HDLc levels, especially >190 mg/dl, are consistently associated with increased risk of CAC progression. Our results suggest that among lipid fractions, non-HDLc may be best suited for the prediction of future CAC progression.

Comparative analysis of red cell distribution width and high sensitivity C-reactive protein for coronary heart disease mortality prediction in multi-ethnic population: findings from the 1999-2004 NHANES

BACKGROUND

Red cell distribution width (RDW) has been shown to predict all-cause and cardiovascular (CVD) mortality. However, the predictive ability of RDW for future coronary heart disease (CHD) mortality in comparison to high sensitivity C-reactive protein (hs-CRP) has not been assessed in a population cohort free of CVD.

METHODS

Analysis was performed on 8,513 adult participants (age > 20 years) free of CVD from the National Health and Nutrition Examination Surveys 1999-2004. Cox-proportional hazard analyses were used to assess the role of RDW and hs-CRP in CHD mortality and in subgroups based on high and low RDW and hs-CRP.

RESULTS

On adjustment for traditional risk factors (age, sex, systolic blood pressure, anti-hypertensive medication use, total cholesterol, high density lipoprotein cholesterol, lipid lowering therapy, smoking, diabetes mellitus, anemia, mean corpuscular volume and nutritional deficiencies), RDW [hazard ratio (HR) 1.26 95% Confidence Interval (CI) [1.12-1.42] p < 0.001] remained an independent predictor, while hs-CRP [HR 1.18 95% CI [0.98-1.41] p = 0.077] did not. On comparative analysis, high RDW (> 12.6%) was predictive of CHD mortality irrespective of hs-CRP status [hs-CRP ≤ 3 mg/L (HR 1.17 95% CI [1.01-1.36] p = 0.031)] and hs-CRP > 3 mg/L (HR 1.44 95% CI [1.23-1.68] p < 0.001). Hs-CRP was not predictive in either high or low RDW subgroup.

CONCLUSION

RDW but not hs-CRP was associated with CHD mortality independent of traditional risk factors in a cohort with no pre-existing CVD. RDW may be considered a stronger biomarker for CHD death than hs-CRP and needs further prospective evaluation in CVD risk assessment.

Gender and ethnic differences in red cell distribution width and its association with mortality among low risk healthy United state adults

Limited information is available about gender and ethnic differences in red cell distribution width (RCDW) with regard to its relation to mortality in a population free of cardiovascular (CV) disease and diabetes. To assess gender and ethnic differences in RCDW and their effect on the association between RCDW and mortality, the Third National Health and Nutritional Examination Survey (n = 15,460, 1988 to 1994) data were examined. Multivariate adjusted Cox proportional hazard analysis was performed to assess effect of gender and ethnicity on the association between RCDW and mortality (total, CV disease, and coronary heart disease [CHD]). RCDW (mean ± SE) was greater in black women (13.1 ± 0.03) and men (13.4 ± 0.02) compared to women of white (12.9 ± 0.02) and other (13.0 ± 0.07) ethnicities and men of white (13.3 ± 0.02) and other (13.3 ± 0.07) ethnicities, respectively (p <0.001). The interaction between RCDW and gender was statistically significant for all study outcomes (p <0.001) but nonsignificant for RCDW and ethnicity. After adjusting for key variables, RCDW in women was associated with adjusted hazard ratios of 1.22 (95% confidence interval [CI] 1.14 to 1.31) for all-cause mortality, 1.17 (95% CI 1.07 to 1.28) for CV deaths, and 1.18 (95% CI 1.03 to 1.35) for CHD deaths; in men, adjusted hazard ratios were 1.29 (95% CI 1.20 to 1.38) for all-cause mortality, 1.27 (95% CI 1.17 to 1.37) for CV deaths, and 1.25 (95% CI 1.13 to 1.39) for CHD deaths (p <0.05 for all). In conclusion, blacks and men have significantly greater RCDWs compared to whites and women. Greater RCDW is associated with a greater risk of mortality in men compared to women, whereas no effect modification is observed by ethnicity.

Red cell distribution width and risk of peripheral artery disease: Analysis of National Health and Nutrition Examination Survey 1999–2004

Red cell distribution width (RDW) is an independent predictor of the 10-year estimated risk of coronary heart disease (CHD) events. However, RDW’s association with peripheral artery disease (PAD) – a CHD risk equivalent – has not been evaluated to date. In this cross-sectional study, we examined 6950 participants of the National Health and Nutrition Examination Survey, 1999–2004. PAD was defined as an ankle–brachial index below 0.9 ( n = 618). RDW was divided into quartiles (Q) (Q1: ≤ 12.2; Q2: 12.3–12.5; Q3: 12.6–13.0; Q4: ≥ 13.1) and PAD risk was compared across these quartiles using adjusted multivariate logistic regression. A graded increase in prevalent PAD with increasing RDW quartiles was observed (4.2% in Q1 vs 13.9% in Q4; test of trend p < 0.001). Risk of PAD was significantly higher (odds ratio (OR) 1.19, 95% confidence interval (CI): 1.06–1.34; p = 0.003) after adjusting for age, sex, race, body mass index, hypertension, hyperlipidemia, diabetes, smoking, estimated glomerular filtration rate, C-reactive protein, hemoglobin, mean corpuscular volume, and nutritional factors (folate, iron and vitamin B12) deficiencies with each unit (0.1) increase in RDW. Upon receiver-operating characteristics analysis, the predictive accuracy of the American College of Cardiology / American Heart Association (ACC/AHA)-defined PAD screening criteria (for a high-risk population) was 0.657 at best, but improved significantly (0.727) after addition of RDW ( p < 0.0001). In conclusion, higher levels of RDW are independently associated with a higher risk of PAD and can significantly improve the risk prediction beyond that estimated by ACC/AHA-defined PAD screening criteria.

Association of novel biomarkers with future cardiovascular events is influenced by ethnicity: results from a multi-ethnic cohort

BACKGROUND

We sought to define the influence of ethnicity on associations between novel biomarkers and cardiovascular disease (CVD) events among Multi-Ethnic Study of Atherosclerosis (MESA) study participants, a community based population of asymptomatic US adults.

METHODS

Baseline (log transformed) levels of biomarkers namely C-reactive protein (CRP), fibrinogen, interleukin-6 (IL-6), D-dimer, plasmin-antiplasmin complex (PAP) and factor VIII were used to predict the cumulative incidence of all CVD events in an ethnicity stratified study cohort from Cox-proportional hazard analysis where models were adjusted for relevant confounders.

RESULTS

Ethnic cohorts included 2362 Caucasians, 1601 African Americans, 1353 Hispanics, and 751 Chinese. At mean 4.6 years of follow-up, 286 CVD events were identified with cumulative incidence of 11.3% in Caucasians, 9.8% in African Americans, 11.3% in Hispanics and 6.9% in Chinese. Biomarker risk association with CVD events incidence was significantly influenced by ethnicity with positive association (HR, 95% CI, p value) being shown for: CRP among Caucasians only (1.23, 1.04-1.47, <0.01) IL-6 among African Americans only (1.69, 1.15-2.48, <0.01) and fibrinogen among Caucasians (3.05, 1.21-7.69, 0.02), African Americans (3.51, 1.09-11.2, 0.03) and Hispanics (4.16, 1.23-14.1, 0.02) only. None of the biomarkers were able to predict CVD in Chinese. Association between above biomarkers and CVD was bi-directional: cases with CVD events had higher mean levels of biomarkers; cases in higher quartiles of biomarkers had increased cumulative incidence of CVD events.

CONCLUSION

Study results from a vast, ethnically diverse, asymptomatic US adult population suggest that biomarker association with incident CVD events is significantly influenced by ethnicity.

Phantom shocks unmasked: clinical data and proposed mechanism of memory reactivation of past traumatic shocks in patients with implantable cardioverter defibrillators

BACKGROUND

Implantable cardioverter defibrillators (ICD), despite an unequivocal clinical benefit, are known to have a complex psychosocial impact on the patients. ICD shocks and the resultant psychobiological changes are known to contribute to increased levels of anxiety, depression, and post-shock stress symptoms in these patients. Phantom shock is a patient-reported perception of an ICD shock in the absence of any actual shock; however, its pathophysiological understanding is poor.

METHODS

A retrospective chart review of the University hospital ICD patients' database from June 2006 to April 2010 was conducted. A total of 38 patients with documented phantom shocks as cases and 76 age- and sex-matched patients with no phantom shocks as controls were selected from the database. Patient characteristics were analyzed for their potential association with the occurrence of phantom shocks.

RESULTS

Phantom shock patients had higher prevalence of documented depression (31.6%), anxiety (23.7%), and cocaine use (42.1%). Additionally, patients who had previous ICD shock storms were more likely to have phantom shocks (39.5%; p = 0.001). More importantly, no phantom shocks were reported in patients who did not receive defibrillation threshold testing or past ICD shock storms.

CONCLUSIONS

Phantom shocks are primarily observed in ICD patients who had prior exposure to traumatic device shocks and are more common in patients with a history of depression, anxiety, or substance abuse. A pathophysiological mechanism is proposed as a guide to potential prevention.

Abstract P236: Relationship Between Red Cell Distribution Width and Alcohol Intake: An Analysis of the NHANES, 1999 to 2006

Introduction: Moderate alcohol intake has been associated with reduced cardiovascular mortality. Red cell distribution width (RDW) is an emerging cardiovascular risk marker, that is increasingly gaining recognition. No prior study has evaluated the association between alcohol intake and RDW.

Methods: We evaluated 6,424 nationally representative individuals participating in the National Health and Nutrition Examination Survey (NHANES) 1999 to 2006, free of cardiovascular co-morbidities (including coronary heart disease, diabetes, congestive heart failure, stroke and myocardial infarction) at baseline. RDW was divided into quartiles [Quartile 1 (Q1) ≤12 (reference category), Q2: 12.1-12.5; Q3: 12.6-13; Q4: >13] and alcohol intake was categorized by number of drinks per day [<1 drink/day, reference category), 1 drink/day, 2 drinks/day and ≥3 drinks/day]. Multivariate adjusted logistic regression analysis was performed to evaluate the risk relationship between RDW levels and daily alcohol intake.

Results: Mean RDW levels varied inversely with number of drinks per day (12.9 in reference alcohol category versus 12.5 in ≥3 drinks/day, p<0.001). Results of multivariate adjusted logistic regression analysis are shown in Table 1.

Conclusion: Moderate alcohol intake [1 to 2 drinks /day] is associated with more favorable levels of RDW. The association appears to be independent of nutritional deficiencies, inflammatory markers and other conventional cardiovascular risk factors.

Table 1:

Abstract P351: Ethnic Differences in the Risk Estimates of Novel Biomarkers for Future Cardiovascular Outcomes

Background: Elevated inflammatory markers, haemostatic factors as well as homocysteine predict cardiovascular disease (CVD) events and mortality. Although racial/ethnic disparities in CVD risk factors and outcomes exist, comparative data on the predictive utility of novel biomarkers for future CVD events in US ethnic groups is limited.

Methods: The study comprised 6814 asymptomatic men and women (52.85%), aged 45-84 yrs without prior cardiovascular disease, enrolled in the Multi-Ethnic Study of Atherosclerosis [MESA] obtained from NHLBI Data repository. 6270 asymptomatic men and women [1384 Hispanics, 2409 Caucasians, 753 Chinese and 1724 African Americans] with a host of novel biomarkers drawn were considered for this analysis. The CVD events were defined as ALL CVD events and HARD CVD events per MESA protocol (see Table).

Results: A total of 302 all CVD events and 203 hard CVD events were identified during a mean follow up of 4.6 years. We observed significant ethnic differences in the prognostic utility of novel biomarkers for cardiovascular risk assessment, in a large multi-ethnic population of US adults free of clinical cardiovascular disease. While homocysteine emerged as a robust biomarker across racial cohorts, most other biomarkers analyzed predominantly predicted events in Caucasians (see Table).

Conclusion: These findings raise serious concern about the prognostic potential or generalizability of risk stratification tools across racial subsets and underscore the need for further ethnicity-specific research in this area.

Abstract P185: Metabolic Syndrome and Cardiovascular Risk - A Comparative Analysis of Waist-Cricumference and Waist-Height-Ratio for Predictive Accuracy

Introduction: Metabolic syndrome (MS) is an adverse predictor of cardiovascular outcomes. Recently, waist height ratio (WHtR) is shown to correlate better with future cardiovascular risk factors than other anthropometric measures. We sought to determine whether replacing waist circumference (WC) with WHtR in metabolic syndrome diagnostic criteria per National Cholesterol Education Program (NCEP) guidelines improves predictive accuracy for future cardiovascular disease (CVD) events.

Methods: The study cohort consisted of prospectively evaluated 6,702 healthy adults aged 45-84 years enrolled in the Multi-Ethnic Study of Atherosclerosis [MESA] study [Age-: 62±10 years, 47% males, 1473 Hispanics, 2575 Caucasians, 799 Chinese and 1855 African Americans]. Metabolic syndrome (MSwc), at baseline, was defined by NCEP guidelines (n=2,208). Metabolic syndrome (MSwhtr) was redefined using WHtR (≥ 0.5 in both male and females) in place of WC, keeping rest of the components constant as recommended by NCEP (n=2,590). CVD events were defined as All CVD (CVDa) per MESA protocol (See Table ). Unadjusted and adjusted Cox-proportional hazard analysis was performed. Harrell's C-statistics were calculated for the most adjusted models.

Results: Total of 319 CVDa events [n=171 (7.44%) in MSwc group and n=190 (7.34%) in MSwhtr group] were identified during a mean follow up of 4.6 years. Results are displayed in the table .

Conclusion: Predictive accuracy of MS re-defined with WHtR and MS defined with WC per NCEP criteria is comparable.

Red cell distribution width and mortality in predominantly African-American population with decompensated heart failure

INTRODUCTION

Red-cell distribution width (RDW) has been identified as a novel prognostic marker in heart failure patients. However, evidence is limited for its predictive value in the setting of patients hospitalized with decompensated heart failure (DHF) and no data are available for African Americans (AA).

METHODS AND RESULTS

Data that included baseline characteristics, laboratory findings, and discharge medications were collected retrospectively on a total of 789 patients with DHF (mean age 62.7 ± 15.1 years, 50% males and 80% AA), admitted to an urban medical center between January 2007 and August 2007, 145 (18.38%) died during median follow-up of 573 days. Unadjusted and adjusted Cox-proportional hazard models were used to analyze predictive value of discharge RDW on mortality. There was a significant negative association between RDW and statin use, blood hemoglobin levels and mean corpuscular volume (MCV); whereas serum creatinine and blood urea nitrogen (BUN) increased with increasing RDW. A statistically significant graded increase in all-cause mortality with higher RDW quartiles (lowest vs highest quartile), independent of hemoglobin and creatinine levels, was found for all patients (adjusted hazard ratio [HR] 3.21; 95% confidence interval [CI]: 1.77-5.83, P < .05) for AAs (adjusted HR 2.92; 95% CI: 1.50-5.71, P < .05) and for non-AAs (adjusted HR-1.27, 95% CI: 1.03-1.55, P = 0.019; RDW evaluated as continuous variable).

CONCLUSION

Discharge RDW is an independent predictor of all-cause mortality in predominantly AA patients hospitalized with DHF. Further research is warranted to delineate underlying pathophysiological mechanisms including the association between statin use and RDW.

Red cell distribution width and risk of coronary heart disease events

Red cell distribution width (RDW) has emerged as a powerful predictor of all-cause mortality in variety of cardiovascular settings. However, no data are available associating RDW with coronary heart disease (CHD) risk in a healthy and nationally representative multiethnic population. A total of 7,556 participants of the National Health and Nutrition Examination Surveys 1999 to 2006 (age 41.5 ± 15.8 years, 60% women) were divided into 3 categories according to their 10-year Framingham risk of hard CHD events: <10% (n = 6,173, reference category), 10% to 20% (n = 1,093, intermediate-risk category), and >20% (n = 290, high-risk category). Unadjusted and adjusted multivariate logistic regression analyses were performed evaluating RDW as a predictor of CHD risk. Each unit increase (0.1) in RDW posed a statistically significant greater odds of being in the intermediate-risk category (odds ratio -1.35, 95% confidence interval 1.27 to 1.45, p <0.001) and high-risk category (odds ratio -1.38, 95% confidence interval 1.25 to 1.53, p <0.001) compared to the reference category, after adjusting for race, body mass index, estimated glomerular filtration rate, hemoglobin A1c, C-reactive protein, hemoglobin, and mean corpuscular volume. Additional adjustments with serum iron, vitamin B(12), and folic acid levels did not affect the association. Subsequently, we divided participants into 2 categories according to their anemia status (as defined by the World Health Organization) to evaluate its effect. An RDW level greater than the seventy-fifth percentile in both anemic and nonanemic participants was a significant predictor of greater CHD risk while RDW of the seventy-fifth percentile or less in anemic participants failed to predict CHD (compared to nonanemic participants with similar RDW as the reference category). In conclusion, a higher RDW appears to be a powerful independent predictor of future CHD risk.