Gender Differences in the Pursuit of Cardiac Electrophysiology Training in North America

BACKGROUND

Despite the increase in the number of female physicians across most specialties within cardiology, <10% of clinical cardiac electrophysiology (EP) fellows are women.

OBJECTIVES

This study sought to determine the factors that influence fellows-in-training (FITs) to pursue EP as a career choice and whether this differs by gender.

METHODS

The authors conducted an online multiple-choice survey through the American College of Cardiology to assess the decision factors that influence FITs in the United States and Canada to pursue cardiovascular subspecialties.

RESULTS

A total of 933 (30.5%) FITs completed the survey; 129 anticipated specializing in EP, 259 in interventional cardiology (IC), and 545 in a different field or were unsure. A total of 1 in 7 (14%) FITs indicated an interest in EP. Of this group, more men chose EP than women (84% vs 16%; P < 0.001). The most important factor that influenced FITs to pursue EP was a strong interest in the field. Women were more likely to be influenced by having a female role model (P = 0.001) compared with men. After excluding FITs interested in IC, women who deselected EP were more likely than men to be influenced by greater interest in another field (P = 0.004), radiation concerns (P = 0.001), lack of female role models (P = 0.001), a perceived "old boys' club" culture (P = 0.001) and discrimination/harassment concerns (P = 0.001).

CONCLUSIONS

Women are more likely than men to be negatively influenced by many factors when it comes to pursuing EP as a career choice. Addressing those factors will help decrease the gender disparity in the field.

The DISCO study-Does Interventionalists' Sex impact Coronary Outcomes?

OBJECTIVES

To examine the association of operator sex with appropriateness and outcomes of percutaneous coronary intervention (PCI).

BACKGROUND

Recent studies suggest that physician sex may impact outcomes for specific patient cohorts. There are no data evaluating the impact of operator sex on PCI outcomes.

METHODS

We studied the impact of operator sex on PCI outcome and appropriateness among all patients undergoing PCI between January 2010 and December 2017 at 48 non-federal hospitals in Michigan. We used logistic regression models to adjust for baseline risk among patients treated by male versus female operators in the primary analysis.

RESULTS

During this time, 18 female interventionalists and 385 male interventionalists had performed at least one PCI. Female interventionalists performed 6362 (2.7%) of 239,420 cases. There were no differences in the odds of mortality (1.48% vs. 1.56%, adjusted OR [aOR] 1.138, 95% CI: 0.891-1.452), acute kidney injury (3.42% vs. 3.28%, aOR 1.027, 95% CI: 0.819-1.288), transfusion (2.59% vs. 2.85%, aOR 1.168, 95% CI: 0.980-1.390) or major bleeding (0.95% vs. 1.07%, aOR 1.083, 95% CI: 0.825-1.420) between patients treated by female versus male interventionalist. While the absolute differences were small, PCIs performed by female interventional cardiologists were more frequently rated as appropriate (86.64% vs. 84.45%, p-value <0.0001). Female interventional cardiologists more frequently prescribed guideline-directed medical therapy.

CONCLUSIONS

We found no significant differences in risk-adjusted in-hospital outcomes between PCIs performed by female versus male interventional cardiologists in Michigan. Female interventional cardiologists more frequently performed PCI rated as appropriate and had a higher likelihood of prescribing guideline-directed medical therapy.

Effects of Home-Based Cardiac Rehabilitation on Time to Enrollment and Functional Status in Patients With Ischemic Heart Disease

Background

Cardiac rehabilitation is an established performance measure for adults with ischemic heart disease, but patient participation is remarkably low. Home‐based cardiac rehabilitation (HBCR) may be more practical and feasible, but evidence regarding its efficacy is limited. We sought to compare the effects of HBCR versus facility‐based cardiac rehabilitation (FBCR) on functional status in patients with ischemic heart disease.

Methods and Results

This was a pragmatic trial of 237 selected patients with a recent ischemic heart disease event, who enrolled in HBCR or FBCR between August 2015 and September 2017. The primary outcome was 3‐month change in distance completed on a 6‐minute walk test. Secondary outcomes included rehospitalization as well as patient‐reported physical activity, quality of life, and self‐efficacy. Characteristics of the 116 patients enrolled in FBCR and 121 enrolled in HBCR were similar, except the mean time from index event to enrollment was shorter for HBCR (25 versus 77 days; P<0.001). As compared with patients undergoing FBCR, those in HBCR achieved greater 3‐month gains in 6‐minute walk test distance (+95 versus +41 m; P<0.001). After adjusting for demographics, comorbid conditions, and indication, the mean change in 6‐minute walk test distance remained significantly greater for patients enrolled in HBCR (+101 versus +40 m; P<0.001). HBCR participants reported greater improvements in quality of life and physical activity but less improvement in exercise self‐efficacy. There were no deaths or cardiovascular hospitalizations.

Conclusions

Patients enrolled in HBCR achieved greater 3‐month functional gains than those enrolled in FBCR. Our data suggest that HBCR may safely derive equivalent benefits in exercise capacity and overall program efficacy in selected patients.

Registration

URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT02105246.

Perceptions on Diversity in Cardiology: A Survey of Cardiology Fellowship Training Program Directors

Background

The lack of diversity in the cardiovascular physician workforce is thought to be an important driver of racial and sex disparities in cardiac care. Cardiology fellowship program directors play a critical role in shaping the cardiology workforce.

Methods and Results

To assess program directors’ perceptions about diversity and barriers to enhancing diversity, the authors conducted a survey of 513 fellowship program directors or associate directors from 193 unique adult cardiology fellowship training programs. The response rate was 21% of all individuals (110/513) representing 57% of US general adult cardiology training programs (110/193). While 69% of respondents endorsed the belief that diversity is a driver of excellence in health care, only 26% could quote 1 to 2 references to support this statement. Sixty‐three percent of respondents agreed that “our program is diverse already so diversity does not need to be increased.” Only 6% of respondents listed diversity as a top 3 priority when creating the cardiovascular fellowship rank list.

Conclusions

These findings suggest that while program directors generally believe that diversity enhances quality, they are less familiar with the literature that supports that contention and they may not share a unified definition of "diversity." This may result in diversity enhancement having a low priority. The authors propose several strategies to engage fellowship training program directors in efforts to diversify cardiology fellowship training programs.

ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document¹ addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas this document addresses this topic with regard to structural (nonvalvular) heart disease. While dealing with different subjects, the 2 documents do share a common structure and feature some clinical overlap. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association Clinical Practice Guidelines. A separate, independent rating panel scored the 102 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

Career Preferences and Perceptions of Cardiology Among US Internal Medicine Trainees: Factors Influencing Cardiology Career Choice

Importance

Few data exist on internal medicine trainees' selection of cardiology training, although this is important for meeting future cardiology workforce needs.

Objective

To discover trainees' professional development preferences and perceptions of cardiology, and their relationship to trainees' career choice.

Design, Setting, and Participants

We surveyed trainees to discover their professional development preferences and perceptions of cardiology and the influence of those perceptions and preferences on the trainees' career choices. Participants rated 38 professional development needs and 19 perceptions of cardiology. Data collection took place from February 2009, through January 2010. Data analysis was conducted from May 2017 to December 2017.

Main Outcomes and Measures

Multivariable models were used to determine the association of demographics and survey responses with prospective career choice.

Results

A total of 4850 trainees were contacted, and 1123 trainees (of whom 625 [55.7%] were men) in 198 residency programs completed surveys (23.1% response; mean [SD] age, 29.4 [3.5] years). Principal component analysis of survey responses resulted in 8-factor and 6-factor models. Professional development preferences in descending order of significance were stable hours, family friendliness, female friendliness, the availability of positive role models, financial benefits, professional challenges, patient focus, and the opportunity to have a stimulating career. The top perceptions of cardiology in descending order of significance were adverse job conditions, interference with family life, and a lack of diversity. Women and future noncardiologists valued work-life balance more highly and had more negative perceptions of cardiology than men or future cardiologists, who emphasized the professional advantages available in cardiology. Professional development factors and cardiology perceptions were strongly associated with a decision to pursue or avoid a career in cardiology in both men and women.

Conclusions and Relevance

Alignment of cardiology culture with trainees' preferences and perceptions may assist efforts to ensure the continued attractiveness of cardiology careers and increase the diversity of the cardiology workforce.

Association of Veterans Health Administration Home-Based Programs With Access to and Participation in Cardiac Rehabilitation

This study examines whether implementing new home-based cardiac rehabilitation programs is associated with cardiac rehabilitation participation in the Veterans Health Administration.

ACC/AATS/AHA/ASE/EACTS/HVS/SCA/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for the Treatment of Patients With Severe Aortic Stenosis: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons

The American College of Cardiology collaborated with the American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Valve Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons to develop and evaluate Appropriate Use Criteria (AUC) for the treatment of patients with severe aortic stenosis (AS). This is the first AUC to address the topic of AS and its treatment options, including surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). A number of common patient scenarios experienced in daily practice were developed along with assumptions and definitions for those scenarios, which were all created using guidelines, clinical trial data, and expert opinion in the field of AS. The 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines(1) and its 2017 focused update paper (2) were used as the primary guiding references in developing these indications. The writing group identified 95 clinical scenarios based on patient symptoms and clinical presentation, and up to 6 potential treatment options for those patients. A separate, independent rating panel was asked to score each indication from 1 to 9, with 1-3 categorized as "Rarely Appropriate," 4-6 as "May Be Appropriate," and 7-9 as "Appropriate." After considering factors such as symptom status, left ventricular (LV) function, surgical risk, and the presence of concomitant coronary or other valve disease, the rating panel determined that either SAVR or TAVR is Appropriate in most patients with symptomatic AS at intermediate or high surgical risk; however, situations commonly arise in clinical practice in which the indications for SAVR or TAVR are less clear, including situations in which 1 form of valve replacement would appear reasonable when the other is less so, as do other circumstances in which neither intervention is the suitable treatment option. The purpose of this AUC is to provide guidance to clinicians in the care of patients with severe AS by identifying the reasonable treatment and intervention options available based on the myriad clinical scenarios with which patients present. This AUC document also serves as an educational and quality improvement tool to identify patterns of care and reduce the number of rarely appropriate interventions in clinical practice.

Left ventricular metabolism, function, and sympathetic innervation in men and women with type 1 diabetes

BACKGROUND

In type I diabetes (T1DM), alterations in LV function may occur due to changes in innervation, metabolism, and efficiency.

OBJECTIVES

We evaluated the association between sympathetic nerve function, oxidative metabolism, resting blood flow, LV efficiency and function in healthy diabetics, and assessed gender differences.

METHODS

Cross-sectional study of 45 subjects with T1DM, 60% females, age 34 ± 13 years, and 10 age-matched controls. Positron emission tomography (PET) imaging with [(11)C]acetate and [(11)C]meta-hydroxyephedrine was performed, in addition to cardiac magnetic resonance imaging.

RESULTS

There were no significant differences in LV function, innervation, or oxidative metabolism between T1DM and controls. Cardiac oxidative metabolism was positively associated with higher levels of sympathetic activation, particularly in women. Diabetic women had significantly lower efficiency compared with diabetic men. Resting flow was significantly higher in diabetic women compared with diabetic men, and tended to be higher in female controls as well.

CONCLUSIONS

Measures of myocardial function, metabolism, blood flow, and sympathetic activation were preserved in young, otherwise healthy, T1DM patients. However, T1DM women presented with greater myocardial oxidative metabolism requirements than men. Ongoing studies are evaluating changes over time.

Characteristics and Outcomes of Women Veterans Undergoing Cardiac Catheterization in the Veterans Affairs Healthcare System

Background—

The number of women veterans is increasing, yet little is known about their cardiovascular risk factors, coronary anatomy, cardiac treatments, and outcomes after cardiac catheterization. Prior studies have shown that nonveteran women have more risk factors, receive less aggressive treatment, and have worse outcomes, despite having less obstructive coronary artery disease than men. Whether these differences exist among women veterans in the veterans affairs healthcare system is unknown.

Methods and Results—

Data on 85 936 veterans (3181 women) undergoing initial cardiac catheterization between October 1, 2007, and September 30, 2012, were examined using the national veterans affairs Clinical Assessment Reporting and Tracking (CART) Program. Sex differences in demographics, indications, coronary anatomy, cardiac treatments, and outcomes were analyzed. Women veterans were younger (56.9 versus 63.0 years, P <0.0001) with fewer traditional cardiovascular risk factors, but with more obesity, depression, and posttraumatic stress disorder than men. Women had lower rates of obstructive coronary artery disease than men (22.6% versus 53.3%). Rates of procedural complications were similar in both genders. Adjusted outcomes at 1 year showed women had lower mortality (hazard ratio, 0.74; confidence interval, 0.60–0.92) and less all-cause rehospitalization (hazard ratio, 0.87; confidence interval, 0.82–0.93), but no difference in rates of unplanned percutaneous coronary intervention.

Conclusions—

Women veterans undergoing catheterization are younger, have more obesity, depression, and posttraumatic stress disorder, less obstructive coronary artery disease, and similar long-term outcomes, compared with men. These findings suggest a significant portion of women veterans may have chest pain not attributable to obstructive coronary artery disease. Further research into possible causes, such as endothelial dysfunction or concurrent psychological comorbidities, is needed.

Evolving strategies for the treatment of microvascular angina in women

Microvascular angina, also known as cardiac syndrome X, is characterized by anginal chest pain, at least one cardiovascular risk factor, an abnormal stress test and normal coronary arteries on angiography. It is significantly more common in women than in men. A definitive diagnosis of microvascular angina can be made by invasive or noninvasive methods; a presumptive diagnosis can also be made based on fulfillment of diagnostic criteria. Effective treatment of microvascular angina requires aggressive risk factor modification; exercise is one of the most effective treatment modalities. Several other treatment strategies have been shown to relieve anginal symptoms as well as improve vascular function; these include β-blockers, angiotensin-converting enzyme inhibitors, ranolazine, L-arginine, statin drugs and potentially estrogen replacement therapy. Nitrates may be effective for symptom relief. Further studies are required to determine whether specific treatments are associated with improved survival as well as decreased symptoms.

Abstract 352: A Multimodal Radiation Reduction Intervention for Intra-procedural Radiation Exposure in Patients Undergoing Cardiac Catheterization in Veterans Affairs Hospitals

Background: Radiation exposure to patients from invasive cardiac procedures is substantial and contributes to a significant portion of overall radiation exposure from medical testing. Efforts to minimize intra-procedural radiation exposure are important for patient safety. This pilot study evaluated the effectiveness of a multimodal radiation intervention to reduce intra-procedural radiation exposure.

Methods: Two VA cardiac catheterization laboratories (Site 1, Site 2) were evaluated for baseline radiation dosing use over a three month period. Following this initial run-in period, the operators and cath lab staff underwent a three-tiered intervention: 1) radiation safety and minimization education, 2) an in-lab radiation monitoring protocol with verbal feedback at pre-specified radiation doses and 3) monthly site and provider-specific report cards comparing radiation dose at the site and provider level within the VA system. Radiation dosing (RD, measured as Dose-Area-Product [Gy*cm2]) was then measured following this intervention at monthly intervals over a three-month period.

Results: We examined 624 cases at Site 1 and 258 cases at Site 2 in the pre-intervention period, and 502 (site 1) and 208 (site 2) in the post-intervention period. Site 1 did not differ significantly in median RD following intervention (71.9 Gy*cm2 [IQR 48.0-114.0] pre-intervention versus 79.5 Gy*cm2 [IQR 50.0-124.8] post-intervention, p=0.34; see Fig 1). Site 2 showed a significant decrease in median radiation dose following intervention (118.72 Gy*cm2 [IQR 73.6-190.0] vs. 92.8 Gy*cm2 [IQR 56.6-158.3], p = 0.004, Fig 1). The national median radiation dose over the same time interval did not change significantly (91.53 Gy*cm2 [IQR 58.0-145.4] pre-intervention versus 90.0 Gy*cm2 [IQR 56.3-142.0] post-intervention, p=0.47, Fig 1).

Conclusion: A three-tiered, multi-modal radiation reduction intervention was associated with reduced radiation exposure in a laboratory with high baseline radiation utilization. Similar reductions were not observed in a laboratory with low baseline radiation utilization. These findings suggest that radiation reduction interventions targeted at higher radiation use centers may result in meaningful decreases in patient radiation exposure.

Antiplatelet therapy use and the risk of venous thromboembolic events in the Raloxifene Use for the Heart (RUTH) trial

BACKGROUND

Raloxifene use in postmenopausal women with osteoporosis increases the risk of venous thromboembolic events (VTE) 2-fold compared with placebo. Platelet activation is involved in the pathophysiology of arterial thromboses more than venous thromboses, but aspirin may reduce VTE risk associated with estrogen use. This analysis examines the effects of concomitant antiplatelet therapy on VTE risk in raloxifene-treated women.

METHODS

In the Raloxifene Use for the Heart (RUTH) trial, 10,101 postmenopausal women from 177 sites in 26 countries at increased risk of coronary heart disease (CHD) (primary prevention cohort) or with CHD (secondary prevention cohort) were randomized to placebo or raloxifene 60 mg/day and followed for a median 5.6 years. Reports of clinical symptoms of VTE were assessed. Concomitant use of antiplatelet agents (aspirin, clopidogrel, ticlopidine, dipyridamole) was allowed. Cox proportional hazard models, with use of warfarin, presence of fracture, and hospitalization as covariates, were used to estimate hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

Overall, raloxifene use was associated with an increased VTE risk (HR 1.44, 95% CI 1.06-1.95) vs. placebo. Most women (72%) reported using aspirin, and 14.2% reported using nonaspirin antiplatelet agents during the study period. Users of antiplatelet agents were older, more likely to have CHD, and more likely to be hyperlipidemic. They had a higher VTE risk than nonusers. No difference in VTE risk was observed in women who used raloxifene alone vs. those who used raloxifene with antiplatelet agents during the study. The increase in VTE risk with raloxifene compared with placebo was not different between women who used antiplatelet agents at baseline (HR 1.44, 95% CI 0.98, 2.10) and those who did not use antiplatelet agents (HR 1.37, 95% CI 0.83, 2.27) (interaction p = 0.88). Similar conclusions were noted for aspirin and nonaspirin antiplatelet use.

CONCLUSIONS

In RUTH, postmenopausal women treated with raloxifene had an increased risk of VTE compared with placebo. Concomitant use of aspirin or nonaspirin antiplatelet agents along with raloxifene did not change VTE risk.

How to stay heart healthy in 2011: considerations for the primary prevention of cardiovascular disease in women

More women die of cardiovascular disease than any other cause. Effective primary prevention depends on accurate assessment of risk status. While most risk factors are similar for men and women, risk factors may differ in magnitude between the sexes, and recognition of gender-specific risk factors such as gestational diabetes, hypertensive syndromes of pregnancy and polycystic ovarian syndrome provides opportunities for early intervention and prevention. Obesity, hypertension and hyperlipidemia affect both genders; however, women often postpone addressing these risk factors until later in life. The American Heart Association emphasizes that all women are at cardiovascular risk and should maintain a healthy lifestyle and avoid smoking. Blood pressure, hyperlipidemia and diabetes should be aggressively treated. Current available data regarding proposed preventive drug therapies including daily aspirin, HRT, vitamin D and omega-3 fatty acid supplements will be reviewed.

Gender differences in adverse outcomes after contemporary percutaneous coronary intervention: an analysis from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) percutaneous coronary intervention registry

BACKGROUND

Prior studies have shown a relationship between female gender and adverse outcomes after percutaneous coronary interventions (PCIs). Whether this relationship still exists with contemporary PCI remains to be determined.

METHODS

We evaluated gender differences in clinical outcomes in a large registry of contemporary PCI. Data were prospectively collected from 22,725 consecutive PCIs in a multicenter regional consortium (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) between January 2002 and December 2003. The primary end point was in-hospital all-cause mortality; other clinical outcomes evaluated included in-hospital death, vascular complications, transfusion, postprocedure myocardial infarction, stroke, and a combined major cardiovascular adverse event (MACE) end point including myocardial infarction, death, stroke, emergency coronary artery bypass grafting, and repeated PCI at the same site. Independent predictors of adverse outcomes were identified using multivariate logistic regression analysis.

RESULTS

Compared with men, women were older, had a higher prevalence of comorbidities, and had a significantly higher frequency of adverse outcomes after PCI. After adjustment for baseline demographics, comorbidities, clinical presentation, and lesion characteristics, female gender was associated with an increased risk of in-hospital death, vascular complication, blood transfusion, stroke, and MACE. The relationship between female gender and increased risk of death and MACE was no longer present after further adjustment for kidney function and low body surface area.

CONCLUSIONS

Differences in mortality rates between men and women no longer exist after PCI. However, our data suggest that technological advancements have not completely offset the relationship between gender and adverse outcomes after PCI.

Acute myocardial infarction in two adolescent males

Acute myocardial infarction in previously healthy children is rare in the absence of congenital anomalies. We describe two cases of acute anterior myocardial infarction in adolescent males with no congenital heart disease, without prior history of or risk factors for coronary heart disease, and with no history of drug abuse. These cases illustrate that myocardial infarction in the absence of systemic illness or coronary anomalies can occur in an adolescent population.

Cardiovascular risk, obesity, and myocardial blood flow in postmenopausal women

BACKGROUND

This study was designed to determine whether overweight or obese status is independently associated with myocardial flow reserve (MFR), an established predictor of cardiovascular mortality, in a group of postmenopausal women with no previous cardiovascular disease. Postmenopausal women are the largest group of overweight and physically inactive individuals in the United States. Increased body mass index (BMI) is consistently associated with increased cardiovascular mortality in this population. Whether this is because of obesity itself or the accompanying increase in cardiovascular risk factors (CRFs) remains controversial.

METHODS

We examined the relationship of myocardial blood flow (MBF), coronary vascular resistance, and MFR to BMI in 60 postmenopausal women with no coronary heart disease. Subjects underwent dynamic N-13 ammonia positron emission tomography for the measurement of MBF and MFR. Baseline demographics, CRF, and hemodynamic parameters were recorded for each subject. Datasets were divided into 3 groups according to BMI: normal (18 to 24), overweight (25 to 29), and obese (>or=30).

RESULTS

The overweight and obese groups showed significantly higher resting MBF and lower MFR than the normal-weight group (both P < .001), even after adjusting for CRF. A further analysis of subjects without any CRF (n = 35) showed that the MFR remained significantly lower in the obese compared with normal-weight subjects (P = .05). Levels of known markers of vascular inflammation (high-sensitivity C-reactive protein and homocysteine) and high-density lipoprotein cholesterol levels correlated with declining MFR.

CONCLUSIONS

These findings provide a mechanistic link between obesity and coronary heart disease in this population.

Combined continuous ethinyl estradiol/norethindrone acetate does not improve forearm blood flow in postmenopausal women at risk for cardiovascular events: a pilot study

OBJECTIVE

This study sought to determine whether combined continuous ethinyl estradiol and norethindrone acetate, a postmenopausal hormone therapy (HT) combination designed to have fewer side effects than cyclical therapies and therapies using medroxyprogesterone acetate (MPA), could improve vascular endothelial function in postmenopausal women with risk factors for cardiovascular disease (CVD).

METHODS

Eighteen postmenopausal women (mean age 62 +/- 11 years) participated in a randomized, placebo-controlled, crossover design trial of 10 microg estradiol/1 mg norethindrone acetate given once daily for 3 months, with a 1-month washout period between placebo and active treatment phases. Vascular reactivity was assessed at each phase of the study using high-frequency brachial artery ultrasound in response to flow-mediated hyperemia, cold pressor testing, and sublingual nitroglycerin. Markers of cardiovascular risk, including cholesterol levels, inflammatory markers, fibrinolytic markers, and solubilized adhesion molecules, were also measured at each phase.

RESULTS

We found no significant difference in vascular reactivity measurements during active treatment with ethinyl estradiol/norethindrone acetate vs. placebo. C-reactive protein (CRP) levels increased significantly during active treatment, and high-density lipoprotein (HDL) levels decreased significantly. Vascular cell adhesion molecule-1 (VCAM-1) levels declined during active treatment. Plasminogen activator inhibitor-1 (PAI-1) levels were inversely correlated with flow-mediated hyperemic vascular reactivity, independent of active treatment or placebo phases.

CONCLUSIONS

In this older postmenopausal population with at least one cardiovascular risk factor, treatment with combined continuous ethinyl estradiol and norethindrone acetate failed to improve vascular endothelial function. The agent's proinflammatory effect or subclinical atherosclerosis in this population may have contributed to this finding.

Symptoms of men and women presenting with acute coronary syndromes

This study evaluated symptom similarities and differences between men and women presenting with acute coronary syndromes (ACSs) and determined whether differences in presentation are intrinsic to patient gender or to other factors. This study was a subgroup analysis of patients from an ACS registry. We compared differences in symptom presentation between men and women and analyzed them using binary logistic regression with all variables and 2 x 2 interactions. Patient gender was forced to remain in the models. Women comprised 35% of the 1,941 patients admitted with confirmed ACS. Men were more likely to present with chest pain, left arm pain, or diaphoresis. Nausea was more common in women. Dyspnea did not differ between groups. After binary logistic regression, gender remained a statistically significant predictor of diaphoresis and nausea, but not of chest or left arm pain. We found that differences in occurrence of chest pain and left arm pain between men and women are explainable by differences in co-morbidities and history; the higher occurrence of diaphoresis in men and of nausea in women is partly related to maleness or femaleness. In conclusion, gender should be considered when evaluating patients with symptoms of ACS.

Self-reported physical activity and myocardial flow reserve in postmenopausal women at risk for cardiovascular disease

BACKGROUND

Regular exercise protects against coronary heart disease (CHD) events and improves vascular reactivity. Exercise effects on myocardial flow reserve (MFR) are not well studied.

METHODS

We performed dynamic N-13 ammonia positron emission tomography (PET) in 16 postmenopausal women (60 +/- 6 years) to measure myocardial blood flow (MBF) and MFR. We also obtained information from each woman on her self-reported physical activity.

RESULTS

Of the 16 patients, 6 reported moderate regular physical activity, and 10 did not. Women who reported regular, at least moderate physical activity had a higher percentage increase in adenosine MBF from rest compared with women who did not exercise (268% vs. 129%, p = 0.04) and had a significantly higher mean maximal MFR (3.68 vs. 2.29, p = 0.04).

CONCLUSIONS

These findings provide further mechanistic support for the beneficial cardiovascular effects of exercise.

Management of cardiogenic shock attributable to acute myocardial infarction in the reperfusion era

Cardiogenic shock is the leading cause of death among patients hospitalized with acute myocardial infarction. It is defined as tissue hypoperfusion resulting from ventricular pump failure in the presence of adequate intravascular volume. Rapid assessment and triage of patients presenting in cardiogenic shock followed by appropriate institution of supportive therapies including vasopressor and inotropic agents, mechanical ventilatory support, and intra-aortic balloon pump counterpulsation are critical for effective management of these patients. However, emergency percutaneous coronary intervention or coronary artery bypass graft surgery is required to decrease mortality rates. Novel approaches, including inhibition of nitric oxide synthase and new mechanical support devices, may further decrease mortality rates, which remain high despite reperfusion therapy.

Coronary heart disease in women: what do we know now?

Coronary heart disease is the single leading cause of death in women in the USA, and there is growing recognition that gender-specific efforts must be made to fully understand and appropriately treat the disease in the female population. While increasing attention is being focused on the prevalence of cardiovascular disease in women so that preventive as well as treatment efforts can be marshaled to combat this epidemic, much remains to be carried out. Although risk factors for coronary heart disease are generally similar between men and women, the magnitude of various factors may differ between the genders. Emerging data suggest that coronary heart disease may be a different entity in women compared with men, requiring different preventive, diagnostic and treatment strategies.

Vascular events in the Multiple Outcomes of Raloxifene Evaluation (MORE) trial: incidence, patient characteristics, and effect of raloxifene

OBJECTIVE

To determine the incidence of arterial and venous thromboembolic (VTE) events, to determine the effect of raloxifene on the incidence of combined vascular (arterial and VTE) events, and to identify patient characteristics associated with these vascular events, in women participating in the MORE trial.

DESIGN

In a post hoc analysis using MORE data, arterial, VTE, and combined vascular event rates were compared between participants receiving placebo (n = 2,576) and those receiving 60 mg/d of raloxifene (n = 2,557). Baseline characteristics were compared between those who did and did not experience an arterial event. The same analysis was performed for VTE events.

RESULTS

Overall, during a mean follow-up time of 41 months, 178 women experienced an arterial event and 40 experienced a VTE event. In the placebo group, the incidence of arterial events exceeded VTE events by at least sevenfold. Raloxifene had no significant effect on the incidence of combined vascular events in the overall cohort (hazard ratio 0.95, 95% CI, 0.73-1.24). In a subset of women retrospectively determined to be at increased cardiovascular risk, raloxifene was associated with a lower incidence of combined vascular events (hazard ratio 0.63, 95% CI, 0.40-0.97). Baseline characteristics differed between those who did and those who did not experience an arterial event, but this was generally not the case for VTE events.

CONCLUSIONS

Arterial events were more common than VTE events. The characteristics of women experiencing an arterial event differed from those experiencing a VTE event. Raloxifene had a neutral effect on the risk of combined vascular events in the overall population, and was associated with a reduced combined vascular event rate in women at increased cardiovascular risk. Additional studies are needed to confirm the effect of raloxifene on overall vascular outcomes.

Weight changes and obesity predict impaired resting and endothelium-dependent myocardial blood flow in postmenopausal women

BACKGROUND

Obesity has been associated with impaired endothelial function, but the influence of lifetime weight patterns on endothelial function has not been studied.

HYPOTHESIS

We hypothesized that coronary vascular reactivity would be diminished in postmenopausal women with a history of obesity and frequent weight swings.

METHODS

We performed dynamic N-13 ammonia positron emission tomography in 18 postmenopausal women with cardiac risk factors. Myocardial blood flow (MBF) was measured at rest, after the cold pressor test (CPT), and after adenosine infusion in order to determine baseline and endothelium-dependent and -independent flows, respectively. Myocardial blood flow was corrected for cardiac work by normalizing to the rate-pressure product. Weight history was obtained by standardized questionnaire.

RESULTS

Normalized rest (n-rest) MBF correlated negatively with current weight (r = -0.52, p = 0.026) and weight at age 18 (r = -0.47, p = 0.047). Normalized CPT (n-CPT) MBF correlated inversely with current weight (r = -0.55, p = 0.018), weight at age 18 (r = -0.605, p = 0.008), and highest weight (r = -0.62, p = 0.006). Higher waist circumference predicted lower n-rest MBF (r = -0.52, p = 0.028) and n-CPT MBF (r = -0.48, p = 0.04). The same association was found with hip circumference (r = -0.52, p = 0.028; r = -0.49, p = 0.038, respectively), whereas higher body mass index (BMI) predicted lower n-CPT MBF (r = -0.53, p = 0.02). Women with at least four significant weight swings had lower MBF during rest, CPT, and n-CPT (0.88 vs. 1.19 ml/g/min, p = 0.008; 0.76 vs. 1.23 ml/g/min, p < 0.001; 0.74 vs. 1.10 ml/g/min, p = 0.009, respectively).

CONCLUSIONS

Increased waist and hip circumference, weight, and frequent weight swings are associated with impaired resting and endothelium-dependent MBF in postmenopausal women. These data suggest that lifetime weight patterns may influence cardiovascular risk in women.

Competitive bidding for interventional cardiology supplies: lessons learned during round 2

OBJECTIVE

To assess the magnitude of savings and develop concepts for "best strategies" in reducing costs in the purchasing of high-technology, high-cost materials used in coronary interventions and electrophysiologic treatments.

STUDY DESIGN

Observational experience in competitive bidding for defibrillators, pacemakers, coronary stents, and coronary balloon catheters at a large, midwestern, publicly owned, academic cardiovascular center.

METHODS

Iterative negotiation following a broad request for proposal sent to a diverse group of vending organizations in high-technology areas of cardiology. Product costs and volume usage were assessed before and after the process to estimate annualized cost reduction achieved.

RESULTS

Using a combination of identification of preferred vendors; consignment of supplies; and collaborative consensus among physicians, administration, materials management, purchasing, and vendors, an annualized savings of more than $1.3 million was achieved.

CONCLUSIONS

Aggressive, collaborative, fair, and competitive bidding for high-cost products used for coronary interventions and electrophysiologic treatments leads to substantial cost savings and can promote provider-industry partnerships that further enhance product use, provision, and tracking.

Hormone replacement therapy trials: an update

Recent randomized trials of hormone replacement therapy (HRT) in postmenopausal women are not consistent with the decrease in cardiovascular risk seen in observational studies of hormone therapy users compared with nonusers. Emerging evidence indicates that HRT use in some women with established coronary heart disease may be associated with prothrombotic effects or proinflammatory effects leading to adverse events. In healthy women, the decision to use HRT should be based primarily on noncardiac factors until more data becomes available that is relevant to this population. Several alternatives to HRT, including phytoestrogens and selective estrogen receptor modulators, have favorable effects on cardiovascular risk factors, but their impact on clinical outcomes remains to be determined.

Stent placement for coronary stenosis in Kawasaki disease: case report and literature review

A 48-year-old male patient diagnosed with Kawasaki disease in childhood presented with recurrent angina after undergoing coronary artery bypass surgery in 1996. Percutaneous transluminal coronary angioplasty and intracoronary stent placement to a lesion in the proximal ramus intermedius were performed successfully. This case illustrates the complementary nature of percutaneous and surgical myocardial revascularization strategies in appropriately selected patients with Kawasaki disease.

Myocardial blood flow and flow reserve in response to short-term cyclical hormone replacement therapy in postmenopausal women

OBJECTIVES

To measure the effects of combined cyclical hormone replacement therapy (HRT) on myocardial blood flow (MBF) in postmenopausal women at high risk for coronary heart disease (CHD) and in women with documented CHD.

BACKGROUND

Estrogen restores endothelium-dependent vasodilation in response to acetylcholine in postmenopausal women, and it has a direct, endothelium-independent vasodilatory effect on coronary arteries.

METHODS

To determine whether coronary microcirculation can be affected by short-term, combined HRT, we performed positron emission tomography (PET) in two groups of women without previous HRT. Group I (n = 10) had one or more risk factors for CHD; group II (n = 8) had documented CHD and previous myocardial infarction. Group II was older (54 +/- 4 vs 59 +/- 5 y, P = .03) and had lower total cholesterol levels at baseline because of lipid-lowering therapy (244 +/- 31 vs 203 +/- 40 mg/dL, P = .03). Patients underwent baseline dynamic PET with N-13 ammonia at rest and during maximal adenosine-induced hyperemia to assess MBF. Each then began taking HRT (conjugated equine estrogen alone or with medroxyprogesterone acetate (MPA), administered in cyclical fashion), and returned for follow-up PET 46 +/- 12 days later.

RESULTS

There was no difference in resting MBF between groups I and II prior to starting therapy or at follow-up. Stress MBF and flow reserve (FR) tended to be higher in group I patients at baseline. MBF values remained unchanged at follow-up and resulted in similar FR values at baseline and during HRT for both groups. Women using only estrogen (n = 6) tended to show higher FR values after estrogen therapy, however.

CONCLUSIONS

Short-term HRT in postmenopausal women did not lead to improvements in MBF or FR. Combined cyclical HRT may not exert measurable effects on coronary microcirculation. MPA may attenuate estrogen effects on the coronaries, which may be largely endothelium-dependent.

Improved detection of left main coronary artery disease with attenuation-corrected SPECT

BACKGROUND

Myocardial perfusion imaging has demonstrated a limited sensitivity as a means of accurately identifying left main (LM) coronary disease. Because regional quantitative perfusion biases are eliminated with attenuation corrected (AC) single photon emission computed tomography (SPECT), as compared with uncorrected (NC) SPECT, we hypothesized that AC SPECT would demonstrate increased diagnostic accuracy for the detection of significant LM coronary stenosis.

METHODS AND RESULTS

We studied 28 patients (23 men, 5 women; mean age, 66+/-9 years) with significant LM stenoses (> or =50%) and 34 control patients (27 men, 7 women; mean age, 65+/-11 years) with 2-vessel coronary disease. Rest thallium-201 and stress technetium 99m sestamibi SPECT imaging with and without AC were performed, as described earlier. Both AC and NC images were analyzed visually and quantitatively in comparison with corresponding normal databases. A greater sensitivity for detection of an LM defect pattern (64% vs. 7%, P = .0009) with equivalent specificity (94% vs. 100%, P = not significant) was demonstrated by means of visual analysis of AC SPECT images. More disease was demonstrated in a greater number of territories with AC SPECT images than with NC images (2.14+/-0.97 for AC images vs. 1.43+/-0.84 for NC images, P = .0001). Similar improvement in the detection of LM disease was shown by means of automated quantitative analysis (57% for AC SPECT vs 14% for NC SPECT, P = .0005), again with no loss in specificity.

CONCLUSIONS

AC SPECT with the University of Michigan method in consecutive patients with LM stenoses and a select control population with severity matched multivessel coronary disease significantly improved the diagnostic accuracy of myocardial perfusion imaging for the identification of LM coronary disease, compared with uncorrected SPECT.

Gender differences in myocardial blood flow dynamics: lipid profile and hemodynamic effects

OBJECTIVES

The purpose of the study was to compare myocardial blood flow (MBF) in hyperlipidemic postmenopausal women and age-matched hyperlipidemic men, and to analyze the relationship between cholesterol subfractions and myocardial blood flow in men and women.

BACKGROUND

Women are protected from coronary artery disease (CAD) events until well after menopause, in part due to gender-specific differences in lipid profiles.

METHODS

To examine the effect of these influences on coronary microcirculation, MBF was quantitated with N-13 ammonia/PET (positron emission tomography) at rest and during adenosine hyperemia in 15 women and 15 men, all nondiabetic, who were matched for age and total cholesterol levels (53+/-4 vs. 50+/-8 years, p = NS, 6.44+/-1.1 vs. 6.31+/-0.85 mmol/liter, or 249+/-41 vs. 244+/-33 mg/dl, p = NS).

RESULTS

Women had significantly higher high density lipoprotein (HDL) and lower triglyceride (Tg) levels than did men, and they showed significantly higher resting MBF and stress MBF levels. Significant correlations were found between resting and hyperemic MBF and HDL and Tg levels (r = 0.44, p < 0.02 for stress MBF vs. HDL; r = 0.48, p < 0.007 for stress MBF vs. Tg). Gender was the strongest predictor of hyperemic MBF in multivariate analysis. Women responded to adenosine hyperemia with a significantly higher heart rate than did men, and hemodynamic factors correlated significantly with blood flow both at rest and during stress.

CONCLUSIONS

These data suggest that the favorable lipid profile seen in women may be associated with preserved maximal blood flow in the myocardium.

Myocardial blood flow and coronary flow reserve late after anatomical correction of transposition of the great arteries

OBJECTIVES

Myocardial blood flow (MBF) in children late after arterial switch operation (ASO) was investigated quantitatively by positron emission tomography (PET).

BACKGROUND

In children with transposition of the great arteries (TGA), ASO is widely accepted as the management of choice. The long-term patency of coronary arteries after surgical transfer to the neo-aorta, however, remains a concern.

METHODS

Twenty-two normally developed, symptom-free children were investigated by PET with nitrogen-13 ammonia at rest and during adenosine vasodilation 10+/-1 years after ASO. A subgroup of 15 children (9+/-1 years; group A) had simple TGA and underwent ASO within 20 days after birth while 7 (13+/-3 years; group B) had complex TGA and underwent ASO and correction of associated anomalies later after birth. Ten young, healthy adults (26+/-6 years) served as the control group.

RESULTS

Resting MBF was not different between groups. After correction for the rate-pressure product as an index of cardiac work, younger children of group A had significantly higher MBF at rest compared to healthy adults (102+/-29 vs. 77+/-6 ml/100 g/min; p = 0.012) while flow in group B was not different from the other groups (85+/-22 ml/100 g/min; p = NS). Hyperemic blood flows were significantly lower in both groups after ASO compared to normals (290+/-42 ml/100 g/min for group A, 240+/-28 for group B, 340+/-57 for normals; p < 0.01); thus, coronary flow reserve was significantly lower in both groups after ASO compared to healthy adults (3.0+/-0.6 for group A, 2.9+/-0.6 for group B, 4.6+/-0.9 for normals; p < 0.01).

CONCLUSIONS

Blood flow measurements suggest decreased coronary reserve in the absence of ischemic symptoms in children late after arterial switch repair of TGA. The global impairment of stress flow dynamics may indicate altered vasoreactivity; however, the prognostic significance of these findings needs to be determined.

The role of nitrogen 13 ammonia positron emission tomography in predicting functional outcome after coronary revascularization

BACKGROUND

We sought to evaluate the predictive value of positron emission tomography (PET) by using blood flow imaging with semiquantitative data analysis techniques for predicting recovery of regional function after revascularization. Positron emission tomography in combination with fluorodeoxyglucose (FDG) has been shown to predict tissue recovery after revascularization. Previous studies have suggested a quantitative threshold for perfusion as evaluated by PET that separates scar from viable tissue.

METHODS AND RESULTS

In a group of 25 patients with impaired regional wall motion at baseline as measured by radionuclide ventriculography, we examined the relationship between myocardial blood flow and functional outcome of myocardial segments in patients who underwent coronary revascularization within 2 months after PET. Regional wall motion was graded on a 5-point scale, from normal to dyskinetic. Regional nitrogen 13 (N-13) ammonia uptake values were expressed as a percentage of maximal myocardial N-13 ammonia uptake and compared with values obtained from healthy volunteers. Results were displayed as polar maps, on which regions of interest were placed corresponding to revascularized vascular territories. We were able to show a statistically significant relationship between regional wall motion abnormalities and decreasing blood flow by N-13 ammonia uptake. An N-13 ammonia uptake of greater than 80% for any given segment was highly accurate in predicting normal or nearly normal postoperative regional wall motion, whereas severely decreased ammonia uptake less than 40% showed normalization of regional wall motion in only 13% of segments.

CONCLUSIONS

Relative ammonia uptake of greater than 80% and less than 40% preoperatively had excellent predictive value for functional outcome, but intermediate quantitative ammonia uptake (between 40% to 80%) necessitates additional information to accurately predict functional recovery.