Association of abnormal electrocardiography response on dobutamine stress echocardiogram with longer-term major adverse cardiovascular events in women with symptoms of ischemic heart disease.

Background: Prior work demonstrates patients with positive (+) electrocardiogram (ECG) but negative (-) echocardiogram wall motion abnormalities (WMAs) on dobutamine stress echocardiography (DSE) testing have an elevated of major adverse cardiovascular events (MACEs). In this study, we aimed to evaluate the long-term prognosis of women with suspected ischemia with no obstructive coronary artery (INOCA) disease by utilizing core lab read DSE, specifically focusing on those with + ECG findings. Methods: Among women with signs and symptoms of myocardial ischemia undergoing clinically indicated coronary angiography enrolled in the Women's Ischemia Syndrome Evaluation (WISE) [1997-2001], a prospective cohort study, 99 underwent standardized DSE by site design. Women with positive DSE (n=17), defined as an increase in score based on wall motion scoring index were excluded except for akinetic to dyskinetic (n=10), providing 82 patients in this analysis. ECG was assessed by core laboratory and (+) ECG was defined as >1 mm ST change. Non-obstructive coronary artery disease (CAD) was assessed by core laboratory quantitative coronary angiography and defined as <50% epicardial stenosis. All-cause death follow-up was an average of 8 years, while adjudicated MACE [all-cause mortality, nonfatal myocardial infarction (MI), nonfatal stroke, heart failure hospitalization] was an average of 5.5 years. Comparisons among subject groups [i.e., (+) ECG and (-) ECG] were made using chi-square or Fisher's exact tests for categorical variables and t-test or Wilcoxon rank-sum test for continuous variables. Results: Demographic profile included a mean age 59±10 years; 55% had hypertension (HTN), 29% diabetes mellitus (DM), and 72% non-obstructive CAD. Overall, 9/82 women (11%) had (+) ECG in the absence of WMAs. There were significant differences in family history of CAD (P=0.009) and vasodilator (P=0.042) use between the (+) ECG and (-) ECG groups, but otherwise had no significant demographic or clinical differences. At longer-term follow up, patients with (+) ECG had higher risk of MACE [unadjusted hazard ratio (HR): 4.91, 95% confidence interval (CI): 1.83, 13.19, P=0.002]. Conclusions: Abnormal stress ECG findings on dobutamine stress testing with a negative DSE should be viewed as an indicator of longer-term risk in women with signs and symptoms of ischemia.

Cardiovascular Imaging in Pregnancy: Valvulopathy, Hypertrophic Cardiomyopathy, and Aortopathy.

Pregnancy is associated with profound hemodynamic changes that are particularly impactful in patients with underlying cardiovascular disease. Management of pregnant women with cardiovascular disease requires careful evaluation that considers the well-being of both the woman and the developing fetus. Clinical assessment begins before pregnancy and continues throughout gestation into the post-partum period and is supplemented by cardiac imaging. This review discusses the role of imaging, specifically echocardiography, cardiac MRI, and cardiac CT, in pregnant women with valvular diseases, hypertrophic cardiomyopathy, and aortic pathology.

Artificial Intelligence Advancements in the Cardiovascular Imaging of Coronary Atherosclerosis.

Coronary artery disease is a leading cause of death worldwide. There has been a myriad of advancements in the field of cardiovascular imaging to aid in diagnosis, treatment, and prevention of coronary artery disease. The application of artificial intelligence in medicine, particularly in cardiovascular medicine has erupted in the past decade. This article serves to highlight the highest yield articles within cardiovascular imaging with an emphasis on coronary CT angiography methods for % stenosis evaluation and atherosclerosis quantification for the general cardiologist. The paper finally discusses the evolving paradigm of implementation of artificial intelligence in real world practice.

Contemporary Cardiovascular Imaging Advancements and Social Media.

PURPOSE OF REVIEW: Social media (SoMe) as a means of knowledge dissemination has grown significantly in cardiovascular imaging in recent years. This media platform allows for a free exchange of ideas, the development of new communities, and the ability to disseminate advancements rapidly. While the social media platforms offer limitless potential, their public domain necessitates several important suggestions around best practices. RECENT FINDINGS: In cardiovascular imaging, specific hashtags have emerged to encompass the major modalities to include #EchoFirst, #YesCCT, #WhyCMR, and #CVNuc. Cardiovascular imaging journals have established major presences in the social media space as an avenue to present novel, high-quality, peer-reviewed content to new audiences. SUMMARY: This review paper aims to introduce basic concepts in social media and cardiovascular imaging while highlighting recent topics of high importance, influence, and attention in cardiovascular imaging to include the ISCHEMIA trial, COVID-19, structural imaging, and multimodality advances from throughout 2020.

"Make the Call, Don't Miss a Beat" Campaign: Effect on Emergency Medical Services Use in Women with Heart Attack Signs.

BACKGROUND: Our objective was to evaluate the relationship between the "Make The Call, Don't Miss a Beat" national mass media campaign and emergency medical services (EMS) use among women with possible heart attack symptoms. METHODS: We linked campaign TV public service advertisement data with national EMS activation data for 2010 to 2014. We identified EMS activations (i.e., responses) for possible heart attack symptoms and for unintentional injuries for both women and men. We estimated the impact of the campaign on the fraction of the 1.7 to 15.9 million activations of women with possible heart attack symptoms compared with 1.9 million female activations for unintentional injuries within each EMS agency and month using quasi-binomial logistic regression controlling for time and state. RESULTS: Of the 3,175 U S. counties, 90% were exposed to the campaign. However, less than 2% of U.S. counties reached moderate TV exposure (≥300 gross rating points) during the entire campaign period. We did not observe an increase in the fraction of female activations for possible heart attack during periods or in counties with higher campaign exposure. CONCLUSIONS: This mass media campaign that relied heavily on TV public service advertisements was not associated with increased EMS use by women with possible heart attack symptoms, even among counties that were more highly exposed to the campaign advertisements.

Gender Differences in the Quality of EMS Care Nationwide for Chest Pain and Out-of-Hospital Cardiac Arrest.

BACKGROUND: We sought to determine whether gender disparities exist in the prehospital management of chest pain (CP) or out-of-hospital cardiac arrest (OHCA) among patients who accessed the emergency medical services (EMS) system. METHODS: We obtained 2010-2013 data from the National Emergency Medical Services Information System and identified all EMS activations for CP or OHCA by adults 40 years of age or older. We selected American Heart Association medications and procedures to manage cardiovascular events. We stratified women and men by age (<65 years vs. ≥65 years), race (White vs. Black), clinical condition (CP vs. OHCA), same EMS agency, and calendar year. We determined the gender-specific treatment proportions for each stratum and calculated the weighted percentage difference in treatment between women and men. RESULTS: Approximately 2.4 million CP and 284,000 OHCA activations were analyzed. Women with CP received a lower percentage of recommended treatments than men. For every 100 EMS activations by women with CP, 2.8 fewer received aspirin (95% CI, -4.8 to -0.8). The greatest gap in CP care was that women were significantly less likely to be transported using lights and sirens than men (-4.6%; 95% CI, -8.7% to -0.5%). More than 90% of OHCA activations were resuscitated; however, women were significantly less likely to be resuscitated compared with men (-1.3%; 95% CI, -2.4% to -0.2%). CONCLUSIONS: Small to modest disparities between otherwise similar women and men in the EMS treatment of CP and OHCA suggest the need for further evaluation and research with detailed contextual and outcome data.

Evaluation of an incidental cardiac finding in a patient with bronchitis.

CLINICAL INTRODUCTION: A 63-year-old man with HIV presented with 1 month of dyspnoea and productive cough without orthopnoea. He was afebrile with normal blood pressure, borderline tachycardia and mild pulmonary wheezing. He had exertional hypoxia requiring 4 L per minute of oxygen. No murmurs, jugular venous distention or lower extremity oedema was noted. Clinical evaluation included transthoracic echocardiography (TTE), which showed mild left ventricular hypertrophy with normal size and systolic function. The right ventricle was normal. There was mild aortic insufficiency; other valves were normal. An abnormality was incidentally seen at the aortic root.The patient was treated for bronchitis and chronic obstructive pulmonary disease exacerbation, while further evaluation of the incidental aortic root finding was performed with transoesophageal echocardiography (TEE) and cardiac MRI (CMR). QUESTION: What is the most likely diagnosis for this finding?Sinus of Valsalva aneurysm.Chronic aortic dissection.Left ventricular outflow tract (LVOT) pseudoaneurysm.Right coronary artery aneurysm.Aortic root abscess.

Breast arterial calcification association with coronary artery calcium scoring and implications for cardiovascular risk assessment in women.

Breast arterial calcification (BAC) is a type of medial artery calcification that can be seen incidentally on mammography. Studies have suggested association of BAC with cardiovascular risk factors, coronary artery disease (CAD), and cardiovascular morbidity and mortality. Recently published studies have also suggested a modest correlation of BAC with coronary artery calcium (CAC) scoring. Roughly 40 million mammograms are already performed annually in the United States with overlap in patients that undergo CAD screening via CAC scoring. Thus, identification of cardiovascular risk by demonstrating an association between BAC and CAC may enable an instrumental sex-specific methodology to identify asymptomatic women at risk for CAD. The purpose of this article is to review the current state of the literature for BAC and its association with CAC, to review contemporary breast cancer screening guidelines, and to discuss the clinical implications of these findings.

Estimation of cardiac output and pulmonary vascular resistance by contrast echocardiography transit time measurement: a prospective pilot study.

BACKGROUND: Studies with other imaging modalities have demonstrated a relationship between contrast transit and cardiac output (CO) and pulmonary vascular resistance (PVR). We tested the hypothesis that the transit time during contrast echocardiography could accurately estimate both CO and PVR compared to right heart catheterization (RHC). METHODS: 27 patients scheduled for RHC had 2D-echocardiogram immediately prior to RHC. 3 ml of DEFINITY contrast followed by a 10 ml saline flush was injected, and a multi-cycle echo clip was acquired from the beginning of injection to opacification of the left ventricle. 2D-echo based calculations of CO and PVR along with the DEFINITY-based transit time calculations were subsequently correlated with the RHC-determined CO and PVR. RESULTS: The transit time from full opacification of the right ventricle to full opacification of the left ventricle inversely correlated with CO (r=-0.61, p<0.001). The transit time from peak opacification of the right ventricle to first appearance in the left ventricle moderately correlated with PVR (r=0.46, p<0.01). Previously described echocardiographic methods for the determination of CO (Huntsman method) and PVR (Abbas and Haddad methods) did not correlate with RHC-determined values (p = 0.20 for CO, p = 0.18 and p = 0.22 for PVR, respectively). The contrast transit time method demonstrated reliable intra- (p<0.0001) and inter-observer correlation (p<0.001). CONCLUSIONS: We describe a novel method for the quantification of CO and estimation of PVR using contrast echocardiography transit time. This technique adds to the methodologies used for noninvasive hemodynamic assessment, but requires further validation to determine overall applicability.

Pulmonary hypertension in hypertensive patients: association with diastolic dysfunction and increased pulmonary vascular resistance.

BACKGROUND: Pulmonary hypertension (PH) in patients with systemic hypertension and preserved ejection fraction (PEF) has been described. However, the pathophysiology and consequences are not entirely clear. We sought to distinguish the clinical and anatomic features among hypertensive patients with or without coexistent PH. METHODS: Echocardiograms and records of hypertensive patients with left ventricular (LV) hypertrophy and PEF from January 2009 to January 2011 were reviewed. We identified 174 patients, including 36 with PH (calculated pulmonary artery systolic pressure [PASP] ≥ 35 mmHg), and 138 with normal pulmonary pressures. RESULTS: Hypertensive patients with PH were older (76 ± 13 vs. 65 ± 13 years, P < 0.0001), more often female (91, 70%), had lower estimated glomerular filtration rate (eGFR) (63 ± 44 vs. 88 ± 48 mL/min, P = 0.002), and higher pro-BNP levels (3141 ± 4253 vs. 1219 ± 1900 pg/mL, P = 0.003). PH patients also had larger left atrial areas (23.7 ± 3.8 vs. 20.8 ± 4.6 cm(2) , P = 0.002), evidence of diastolic dysfunction (i.e., septal E/e' 17.6 ± 8.6 vs. 12.7 ± 4.4, P = 0.0005), and higher calculated peripheral vascular resistance (PVR) (2.3 ± 1.1 vs. 1.6 ± 0.4, P < 0.0001). Both PVR and septal E/e' showed strong linear correlation with PASP (P < 0.0001 and P < 0.0001, respectively). CONCLUSIONS: Hypertension in elderly patients is frequently complicated by LV diastolic dysfunction and secondary PH. These hypertensive patients tended to have reduced renal function and higher pro-BNP. Because of the known morbidity and mortality associated with PH, these observations have potentially important implications for target medical therapy.

Genomic profiling reveals the potential role of TCL1A and MDR1 deficiency in chemotherapy-induced cardiotoxicity.

BACKGROUND: Anthracyclines, such as doxorubicin (Adriamycin), are highly effective chemotherapeutic agents, but are well known to cause myocardial dysfunction and life-threatening congestive heart failure (CHF) in some patients. METHODS: To generate new hypotheses about its etiology, genome-wide transcript analysis was performed on whole blood RNA from women that received doxorubicin-based chemotherapy and either did, or did not develop CHF, as defined by ejection fractions (EF)≤40%. Women with non-ischemic cardiomyopathy unrelated to chemotherapy were compared to breast cancer patients prior to chemo with normal EF to identify heart failure-related transcripts in women not receiving chemotherapy. Byproducts of oxidative stress in plasma were measured in a subset of patients. RESULTS: The results indicate that patients treated with doxorubicin showed sustained elevations in oxidative byproducts in plasma. At the RNA level, women who exhibited low EFs after chemotherapy had 260 transcripts that differed >2-fold (p<0.05) compared to women who received chemo but maintained normal EFs. Most of these transcripts (201) were not altered in non-chemotherapy patients with low EFs. Pathway analysis of the differentially expressed genes indicated enrichment in apoptosis-related transcripts. Notably, women with chemo-induced low EFs had a 4.8-fold decrease in T-cell leukemia/lymphoma 1A (TCL1A) transcripts. TCL1A is expressed in both cardiac and skeletal muscle, and is a known co-activator for AKT, one of the major pro-survival factors for cardiomyocytes. Further, women who developed low EFs had a 2-fold lower level of ABCB1 transcript, encoding the multidrug resistance protein 1 (MDR1), which is an efflux pump for doxorubicin, potentially leading to higher cardiac levels of drug. In vitro studies confirmed that inhibition of MDR1 by verapamil in rat H9C2 cardiomyocytes increased their susceptibility to doxorubicin-induced toxicity. CONCLUSIONS: It is proposed that chemo-induced cardiomyopathy may be due to a reduction in TCL1A levels, thereby causing increased apoptotic sensitivity, and leading to reduced cardiac MDR1 levels, causing higher cardiac levels of doxorubicin and intracellular free radicals. If so, screening for TCL1A and MDR1 SNPs or expression level in blood, might identify women at greatest risk of chemo-induced heart failure.

Interpretation of remotely downloaded pocket-size cardiac ultrasound images on a web-enabled smartphone: validation against workstation evaluation.

BACKGROUND: Pocket-size ultrasound has increased echocardiographic portability, but expert point-of-care interpretation may not be readily available. The aim of this study was to test the hypothesis that remote interpretation on a smartphone with dedicated medical imaging software can be as accurate as on a workstation. METHODS: Eighty-nine patients in a remote Honduran village underwent echocardiography by a nonexpert using a pocket-size ultrasound device. Images were sent for verification of point-of-care diagnosis to two expert echocardiographers in the United States reading on a workstation. Studies were then anonymized, randomly ordered, and reinterpreted on a smartphone with a dedicated, Health Insurance Portability and Accountability Act-compliant application. Point-of-care diagnosis was considered accurate if any abnormal finding was matched and categorized at the same level of severity (mild, moderate, or severe) by either expert interpretation. RESULTS: The mean age was 54 ± 23 years, and 57% of patients were women. The most common indications for echocardiography were arrhythmia (33%), cardiomyopathy (28%), and syncope (15%). Using the workstation, point-of-care diagnoses were changed in 38% of cases by expert overread (41% left ventricular function correction, 38% valvulopathy correction, 18% poor image quality). Expert interobserver agreement was excellent at 82%, with a Cohen's κ value of 0.82 (95% confidence interval, 0.70-0.94). Intraobserver agreement comparing interpretations on workstations and smartphones was 90%, with a Cohen's κ value of 0.86 (95% confidence interval, 0.76-0.97), signifying excellent intertechnology agreement. CONCLUSIONS: Remote expert echocardiographic interpretation can provide backup support to point-of-care diagnosis by nonexperts when read on a dedicated smartphone-based application. Mobile-to-mobile consultation may improve access in previously inaccessible locations to accurate echocardiographic interpretation by experienced cardiologists.

Estimation of right atrial and ventricular hemodynamics by CT coronary angiography.

BACKGROUND: Computed tomography coronary angiography (CTCA) provides an accurate noninvasive alternative to the invasive assessment of coronary artery disease. However, a specific limitation of CTCA is inability to assess hemodynamic data. OBJECTIVE: We hypothesized that CTCA-derived measurements of contrast within the superior vena cava (SVC) and inferior vena cava (IVC) would correlate to echocardiographic estimations of right atrial and right ventricular pressures. METHODS: Medical records of all patients who underwent both echocardiography and CTCA in our center were reviewed (n = 32). Standard CTCA was performed with a 64-detector CT using test-bolus method for image acquisition timing and iso-osmolar contrast injection through upper extremity vein. The length of the column of contrast reflux into the inferior vena cava (IVC) was correlated to echocardiographically determine tricuspid regurgitation jet velocity (TRV). SVC area change with contrast injection at the level of the bifurcation of the pulmonary artery was also correlated with IVC sniff response by echocardiogram. RESULTS: The reflux column length was interpretable in 27 of 32 patients with a mean length of 10.1 ± 1.1 mm, and a significant bivariate correlation was observed between reflux column length and the tricuspid regurgitant jet velocity (r = 0.84; P < .0001). Mean SVC distensibility ratio was 0.63 ± 0.03; mean IVC sniff response ratio was 0.53 ± 0.03. SVC distensibility correlated to IVC sniff response with a Pearson r of 0.57 (P = .04). CONCLUSION: Quantification of IVC and SVC contrast characteristics during CTCA provides a feasible and potentially accurate method of estimating right atrial and ventricular pressure.

Left ventricular dyssynchrony in hypertensive patients without congestive heart failure.

BACKGROUND: Normal left ventricular (LV) systolic function is present in as many as 50% of patients with congestive heart failure. The majority of such patients have systemic hypertension. Recent studies have demonstrated LV dyssynchrony among patients with heart failure and normal systolic function. However, it is unclear whether such abnormalities exist in hypertensive patients who have not developed clinical evidence of heart failure. METHODS: Hospitalized patients with established hypertension undergoing echocardiography who met the following criteria were eligible for the study: LV ejection fraction (EF) >or= 50%, wall >or=11 mm, absence of valvular or known ischemic disease, and normal QRS duration. Complete 2-Dimensional and Doppler echocardiography studies with tissue Doppler imaging (TDI) were performed in all patients. Dyssynchrony was measured using time from QRS to peak systolic velocity on TDI (T-P) in 3 apical views. Normal values for dyssynchrony were established in a group of normotensive patients with normal echocardiography studies. RESULTS: The study included 42 patients (19 women, 23 men with a, mean age of 59.6 y (range 32-96 y). Left ventricular dyssynchrony was common, occurring in 20 of 42 patients (47.6%). Dyssynchrony assessed with the maximum T-P (T-Pmax) was significantly related to LV mass (r = 0.32, p = 0.036), left atrial volume (r = 0.59, p < 0.0001), and LV sphericity index (0.32, p = 0.037). Dyssynchrony was not related to age or LV filling pressure calculated from the Doppler study. CONCLUSIONS: Left ventricular dyssynchrony is common among hypertensive patients with normal LV systolic function and no evidence of congestive heart failure. The severity of LV dyssynchrony is related to the magnitude of LV hypertrophy, left atrial size, and LV remodeling.

Exercise treadmill testing using a modified exercise protocol in women with suspected myocardial ischemia: findings from the National Heart, Lung and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE).

BACKGROUND: Exercise testing, a major diagnostic modality in individuals with suspected coronary artery disease (CAD), has in general demonstrated less overall diagnostic accuracy in women compared to men. As part of the WISE, a modified protocol was examined with the intention of improving reliability of exercise testing. METHODS: Criteria for entry in the WISE study include clinically indicated coronary angiography. Exercise testing was performed using a protocol modified to be more appropriate for women. The study population consisted of 96 women, mean age of 55.8 y (range 34-77), who completed exercise treadmill test (ETT). Most (78%) were postmenopausal; 96% had >or =2 risk factors for CAD. RESULTS: By core laboratory angiography, 29/96 women had stenosis > or =50% in at least one coronary artery. Of these 29 women, 9 had abnormal ETT, yielding overall sensitivity of 31%. The remaining 20 women had normal (12/29, 41%) or nondiagnostic (8/29, 28%) studies. Among the 67 women with minimal or no coronary stenosis, 35 had no ischemic ST-segment changes during ETT, yielding overall specificity of 52%. Analysis with exclusion of women with nondiagnostic studies yielded sensitivity and specificity of 43% and 66%, respectively. The presence of coronary artery stenosis and inability to perform ETT, but not results of testing, predicted the outcomes of myocardial infarction, heart failure, and death. CONCLUSIONS: Exercise treadmill test appears to be of limited diagnostic value in women with suspected myocardial ischemia referred for coronary angiography. Sensitivity and specificity remain poor even with modified exercise protocol and core laboratory angiographic analysis. These findings merit consideration in view of current guidelines that recommend exercise testing in women with suspected CAD.

Influence of gender and race on hemodynamic response to dobutamine during dobutamine stress echocardiography.

This study sought to determine the influence of gender and/or race on the hemodynamic response to dobutamine during dobutamine stress echocardiography. Blood pressure response patterns differed by gender and race, and completion of testing was often limited because of adverse events, namely, hypertension. Gender and racial differences in blood pressure response merit consideration as potential contributors to the suboptimal response in dobutamine stress testing.

Delayed presentation of left ventricular outflow tract aneurysm after penetrating cardiac trauma.

We report a case of posttraumatic left ventricular outflow tract aneurysm in a patient who had a stab injury to the chest requiring emergency operation 40 years previously. After apparent decades without symptoms, the patient presented with exertional dyspnea. Clinical and echocardiographic assessment revealed aortic regurgitation and left ventricular outflow tract aneurysm. Injuries to the chest wall that penetrate the heart and great vessels are life-threatening and require emergency operative intervention. However, these injuries rarely, as in this case, result in chronic cardiac aneurysm and aortic valvular incompetence.