Racial Diversity Among American Cardiologists: Implications for the Past, Present, and Future.

In the United States, race-based disparities in cardiovascular disease care have proven to be pervasive, deadly, and expensive. African American/Black, Hispanic/Latinx, and Native/Indigenous American individuals are at an increased risk of cardiovascular disease and are less likely to receive high-quality, evidence-based medical care as compared with their White American counterparts. Although the United States population is diverse, the cardiovascular workforce that provides its much-needed care lacks diversity. The available data show that care provided by physicians from racially diverse backgrounds is associated with better quality, both for minoritized patients and for majority patients. Not only is cardiovascular workforce diversity associated with improvements in health care quality, but racial diversity among academic teams and research scientists is linked with research quality. We outline documented barriers to achieving workforce diversity and suggest evidence-based strategies to overcome these barriers. Key strategies to enhance racial diversity in cardiology include improving recruitment and retention of racially diverse members of the cardiology workforce and focusing on cardiovascular health equity for patients. This review draws attention to academic institutions, but the implications should be considered relevant for nonacademic and community settings as well.

Particulate Matter Air Pollution and Racial Differences in Cardiovascular Disease Risk.

OBJECTIVE: We aimed to assess racial differences in air pollution exposures to ambient fine particulate matter (particles with median aerodynamic diameter <2.5 µm [PM2.5]) and black carbon (BC) and their association with cardiovascular disease (CVD) risk factors, arterial endothelial function, incident CVD events, and all-cause mortality. APPROACH AND RESULTS: Data from the HeartSCORE study (Heart Strategies Concentrating on Risk Evaluation) were used to estimate 1-year average air pollution exposure to PM2.5 and BC using land use regression models. Correlates of PM2.5 and BC were assessed using linear regression models. Associations with clinical outcomes were determined using Cox proportional hazards models, adjusting for traditional CVD risk factors. Data were available on 1717 participants (66% women; 45% blacks; 59±8 years). Blacks had significantly higher exposure to PM2.5 (mean 16.1±0.75 versus 15.7±0.73µg/m3; P=0.001) and BC (1.19±0.11 versus 1.16±0.13abs; P=0.001) compared with whites. Exposure to PM2.5, but not BC, was independently associated with higher blood glucose and worse arterial endothelial function. PM2.5 was associated with a higher risk of incident CVD events and all-cause mortality combined for median follow-up of 8.3 years. Blacks had 1.45 (95% CI, 1.00-2.09) higher risk of combined CVD events and all-cause mortality than whites in models adjusted for relevant covariates. This association was modestly attenuated with adjustment for PM2.5. CONCLUSIONS: PM2.5 exposure was associated with elevated blood glucose, worse endothelial function, and incident CVD events and all-cause mortality. Blacks had a higher rate of incident CVD events and all-cause mortality than whites that was only partly explained by higher exposure to PM2.5.

Rationale and Design for the Remote Ischemic Preconditioning for Carotid Endarterectomy Trial.

BACKGROUND: While the perioperative stroke rate after carotid endarterectomy (CEA) is low, "silent" microinfarctions identified by magnetic resonance imaging (MRI) are common and have been correlated with postoperative neurocognitive decline. Our study will investigate the role of remote ischemic preconditioning (RIPC) as a potential neuroprotective mechanism. RIPC is a well-tolerated stimulus that, through neuronal and humoral pathways, generates a systemic environment of greater resistance to subsequent ischemic insults. We hypothesized that patients undergoing RIPC before CEA will have improved postoperative neurocognitive scores compared with those of patients undergoing standard care. METHODS: Patients undergoing CEA will be randomized 1:1 to RIPC or standard clinical care. Those randomized to RIPC will undergo a standard protocol of 4 cycles of RIPC. Each RIPC cycle will involve 5 min of forearm ischemia with 5 min of reperfusion. Forearm ischemia will be induced by a blood pressure cuff inflated to 200 mm Hg or at least 15 mm Hg higher than the systolic pressure if it is >185 mm Hg. This will occur after anesthesia induction and during incision/dissection but before manipulation or clamping of the carotid; thus, patients will be blinded to their assignment. Before carotid endarterectomy, all patients will undergo baseline neurocognitive testing in the form of a Montreal Cognitive Assessment (MoCA) and National Institutes of Health (NIH) Toolbox. MoCA testing only will be conducted on postoperative day 1 in the hospital. The full neurocognitive testing battery will again be conducted at 1-month follow-up in the office. Changes from baseline will be compared between arms at the follow-up time points. Assuming no drop-ins or dropouts and a 10% loss to follow-up, we would need a sample size of 43 patients for 80% power per treatment arm. The primary endpoint, change in MoCA scores, will be analyzed using a random effects model, and secondary outcomes will be analyzed using either linear or logistic regression where appropriate. CONCLUSIONS: RIPC, if shown to be effective in protecting patients from neurocognitive decline after CEA, represents a safe, inexpensive, and easily implementable method of neuroprotection.

Association of obstructive sleep apnea with microvascular endothelial dysfunction and subclinical coronary artery disease in a community-based population.

Studies have reported an association between obstructive sleep apnea (OSA) and cardiovascular disease (CVD) morbidity and mortality. Proposed mechanisms include endothelial dysfunction and atherosclerosis. We aimed to investigate the associations of OSA with endothelial dysfunction and subclinical atherosclerotic coronary artery disease (CAD), and assess the impact of race on these associations. We used data from the Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) study, a community-based prospective cohort with approximately equal representation of black and white participants. OSA severity was measured in 765 individuals using the apnea-hypopnea index (AHI). Endothelial dysfunction was measured using the Endo-PAT device, expressed as Framingham reactive hyperemia index (F_RHI). Coronary artery calcium (CAC), a marker of subclinical CAD, was quantified by electron beam computed tomography. There were 498 (65%) female participants, 282 (37%) black individuals, and 204 (26%) participants with moderate/severe OSA (AHI ≥15). In univariate models, moderate/severe OSA was associated with lower F_RHI and higher CAC, as well as several traditional CVD risk factors including older age, male sex, hypertension, diabetes, higher body mass index, and lower high-density lipoprotein cholesterol levels. In a multivariable model, individuals with moderate/severe OSA had 10% lower F_RHI and 35% higher CAC, which did not reach statistical significance ( p=0.08 for both comparisons). There was no significant interaction of race on the association of OSA with F_RHI or CAC ( p-value >0.1 for all comparisons). In a community-based cohort comprised of black and white participants, moderate/severe OSA was modestly associated with endothelial dysfunction and subclinical atherosclerotic CAD. These associations did not vary by race.

Renal Protection Using Remote Ischemic Peri-Conditioning During Inter-Facility Helicopter Transport of Patients With ST-Segment Elevation Myocardial Infarction: A Retrospective Study.

OBJECTIVE: To assess the impact of remote ischemic peri-conditioning (RIPC) during inter-facility air medical transport of ST-segment elevation myocardial infarction (STEMI) patients on the incidence of acute kidney injury (AKI) following primary percutaneous coronary intervention (pPCI). BACKGROUND: STEMI patients who receive pPCI have an increased risk of AKI for which there is no well-defined prophylactic therapy in the setting of emergent pPCI. METHODS: Using the ACTION Registry-GWTG, we evaluated the impact of RIPC applied during inter-facility helicopter transport of STEMI patients from non-PCI capable hospitals to 2 PCI-hospitals in the United States between March, 2013 and September, 2015 on the incidence of AKI following pPCI. AKI was defined as ≥0.3 mg/dL increase in creatinine within 48-72 hours after pPCI. RESULTS: Patients who received RIPC (n = 127), compared to those who did not (n = 92), were less likely to have AKI (11 of 127 patients [8.7%] vs. 17 of 92 patients [18.5%]; adjusted odds ratio = 0.32, 95% CI 0.12-0.85, P = 0.023) and all-cause in-hospital mortality (2 of 127 patients [1.6%] vs. 7 of 92 patients [7.6%]; adjusted odds ratio = 0.14, 95% CI 0.02-0.86, P = 0.034) after adjusting for socio-demographic and clinical characteristics. There was no difference in hospital length of stay (3 days [interquartile range, 2-4] vs. 3 days [interquartile range, 2-5], P = 0.357) between the 2 groups. CONCLUSION: RIPC applied during inter-facility helicopter transport of STEMI patients for pPCI is associated with lower incidence of AKI and in-hospital mortality. The use of RIPC for renal protection in STEMI patients warrants further in depth investigation.

Feasibility of Remote Ischemic Peri-conditioning during Air Medical Transport of STEMI Patients.

Remote ischemic peri-conditioning (RIPC) has gained interest as a means of reducing ischemic injury in patients with acute ST-elevation myocardial infarction (STEMI) who are undergoing emergent primary percutaneous coronary intervention (pPCI). We aimed to evaluate the feasibility, process, and patient-related factors related to the delivery of RIPC during air medical transport of STEMI patients to tertiary pPCI centers. We performed a retrospective review of procedural outcomes of a cohort of STEMI patients who received RIPC as part of a clinical protocol in a multi-state air medical service over 16 months (March 2013 to June 2014). Eligible patients were transported to two tertiary PCI centers and received up to four cycles of RIPC by inflating a blood pressure cuff on an upper arm to 200 mmHg for 5 minutes and subsequently deflating the cuff for 5 minutes. Data regarding feasibility, process variables, patient comfort, and occurrence of hypotension were obtained from prehospital records and prospectively completed quality improvement surveys. The primary outcome was whether at least 3 cycles of RIPC were completed by air medical transport crews prior to pPCI. Secondary outcomes included the number of cycles completed prior to pPCI, time spent with the patient prior to transport (bedside time), patient discomfort level, and incidence of hypotension (systolic blood pressure <90 mmHg) during the procedure. RIPC was initiated in 99 patients (91 interfacility, 8 scene transports) and 83 (83.3%) received 3 or 4 cycles of RIPC, delivered over 25-35 minutes. Median bedside time for interfacility transfers was 8 minutes (IQR 7, 10). More than half of patients reported no pain related to the procedure (N = 53, 53.3%), whereas 5 (5.1%) patients reported discomfort greater than 5 out of 10. Two patients developed hypotension while receiving RIPC and both had experienced hypotension prior to initiation of RIPC. RIPC is feasible and safe to implement for STEMI patients undergoing air medical transport for pPCI, without occurrence of prolonged bedside times. The incidence of excessive RIPC-related discomfort or hemodynamic instability is rare. STEMI patients requiring on average >30 minutes transport for pPCI may be the ideal group for RIPC utilization.

Effect of aspirin on acute changes in peripheral arterial stiffness and endothelial function following exertional heat stress in firefighters: The factorial group results of the Enhanced Firefighter Rehab Trial.

Peripheral arterial stiffness and endothelial function, which are independent predictors of cardiac events, are abnormal in firefighters. We examined the effects of aspirin on peripheral arterial stiffness and endothelial function in firefighters. Fifty-two firefighters were randomized to receive daily 81 mg aspirin or placebo for 14 days before treadmill exercise in thermal protection clothing, and a single dose of 325 mg aspirin or placebo immediately following exertion. Peripheral arterial augmentation index adjusted for a heart rate of 75 (AI75) and reactive hyperemia index (RHI) were determined immediately before, and 30, 60, and 90 minutes after exertion. Low-dose aspirin was associated with lower AI75 (-15.25±9.25 vs -8.08±10.70, p=0.014) but not RHI. On repeated measures analysis, treatment with low-dose aspirin before, but not single-dose aspirin after exertion, was associated with lower AI75 following exertional heat stress (p=0.018). Low-dose aspirin improved peripheral arterial stiffness and wave reflection but not endothelial function in firefighters.

Obstructive sleep apnea and dyslipidemia: evidence and underlying mechanism.

INTRODUCTION: Over the past half century, evidence has been accumulating on the emergence of obstructive sleep apnea (OSA), the most prevalent sleep-disordered breathing, as a major risk factor for cardiovascular disease. A significant body of research has been focused on elucidating the complex interplay between OSA and cardiovascular risk factors, including dyslipidemia, obesity, hypertension, and diabetes mellitus that portend increased morbidity and mortality in susceptible individuals. CONCLUSION: Although a clear causal relationship of OSA and dyslipidemia is yet to be demonstrated, there is increasing evidence that chronic intermittent hypoxia, a major component of OSA, is independently associated and possibly the root cause of the dyslipidemia via the generation of stearoyl-coenzyme A desaturase-1 and reactive oxygen species, peroxidation of lipids, and sympathetic system dysfunction. The aim of this review is to highlight the relationship between OSA and dyslipidemia in the development of atherosclerosis and present the pathophysiologic mechanisms linking its association to clinical disease. Issues relating to epidemiology, confounding factors, significant gaps in research and future directions are also discussed.

Temporal trends in the utilization and outcome of transcatheter aortic valve replacement across racial and ethnic groups. A nationwide analysis.

BACKGROUND: Transcatheter aortic valvular replacement (TAVR) improves outcomes in patients with aortic stenosis (AS). However, data describing racial disparities in the utilization and outcomes of TAVR are limited. We aimed to evaluate the utilization trends and outcomes of TAVR across racial and ethnic groups. METHODS: All patients who underwent TAVR in the United States from 2016 through 2020 were identified from the National Inpatient Sample database. Patients were classified according to their racial and ethnic groups as Non-Hispanic White (NHW), Non-Hispanic Black (NHB), Hispanic, and Asian. We assessed racial and ethnic differences in the outcomes of TAVR using multivariate logistic regression analysis adjusting for age, sex, insurance, income, hospital location and teaching status, bed size, region, and the Charlson Comorbidity Index. RESULTS: Of the 280,290 patients who underwent TAVR, 89.5% were NHW, 4.24% were NHB, 4.9% were Hispanic, and 1.39% were Asian people. In 2016, the rates of all-TAVR procedures were 1.48 per 1000 patients among NHW group but 0.39 in NHB, 0.4 in Hispanic, and 0.47 in the Asian group. A steep rise was noted in the rate of TAVR among NHW but not in the NHB, Hispanic, and Asian groups. NHB patients had lower mortality rates (adjusted Odds Ratio [aOR]: 0.56; CI 0.35-0.88 p = 0.014) compared to their NHW counterparts. CONCLUSION: The racial and ethnic gap in the utilization of TAVR widened during the study period with minority groups being disproportionately less likely to receive TAVR. NHB patients who received TAVR had lower mortality rates than NHW.

Obstructive sleep apnea and cardiovascular disease in blacks: a call to action from the Association of Black Cardiologists.

Obstructive sleep apnea (OSA) has emerged as a new and important risk factor for cardiovascular disease (CVD). Over the last decade, epidemiologic and clinical research has consistently supported the association of OSA with increased cardiovascular (CV) morbidity and mortality. Such evidence prompted the American Heart Association to issue a scientific statement describing the need to recognize OSA as an important target for therapy in reducing CV risk. Emerging facts suggest that marked racial differences exist in the association of OSA with CVD. Although both conditions are more prevalent in blacks, almost all National Institutes of Health-funded research projects evaluating the relationship between OSA and CV risk have been conducted in predominantly white populations. There is an urgent need for research studies investigating the CV impact of OSA among high-risk minorities, especially blacks. This article first examines the evidence supporting the association between OSA and CVD and reviews the influence of ethnic/racial differences on this association. Public health implications of OSA and future directions, especially regarding minority populations, are discussed.

Nonischemic mitral regurgitation: prognostic value of nonsustained ventricular tachycardia after mitral valve surgery.

BACKGROUND: Nonsustained ventricular tachycardia (VT), frequent in unoperated severe mitral regurgitation (MR), confers mortality risk [sudden death (SD) and cardiac death (CD)]. The prognostic value of VT after mitral valve surgery (MVS) is unknown; we aimed to define this prognostic value and to assess its modulation by left (LV) and/or right (RV) ventricular ejection fraction (EF) for mortality after MVS. METHODS: In 57 patients (53% females, aged 58 ± 12 years) with severe MR prospectively followed before and after MVS, we performed 24-hour ambulatory electrocardiograms approximately annually. LVEF and RVEF were determined within 1 year after MVS by radionuclide cineangiography. RESULTS: During 9.52 ± 3.49 endpoint-free follow-up years, late postoperative CD occurred in 11 patients (7 SD, 4 heart failures). In univariable analysis, >1 VT episode after MVS predicted SD (p < 0.01) and CD (SD or heart failure; p < 0.04). Subnormal postoperative RVEF predicted CD (p < 0.04). When adjusted for preoperative age, gender, etiology or antiarrhythmics, both postoperative VT and RVEF predicted CD (p ≤ 0.05). When postoperative VT and RVEF were both in the multivariable model, only subnormal RVEF predicted CD (p < 0.04). Among those with normal RVEF, VT >1 episode predicted SD (p = 0.03). CONCLUSION: Postoperative VT and subnormal RVEF predict late postoperative deaths in nonischemic MR. Their assessment may aid patient management.

Beliefs and attitudes toward obstructive sleep apnea evaluation and treatment among blacks.

OBJECTIVE: Although blacks are at higher risk for obstructive sleep apnea (OSA), they are not as likely as their white counterparts to receive OSA evaluation and treatment. This study assessed knowledge, beliefs, and attitudes towards OSA evaluation and treatment among blacks residing in Brooklyn, New York. METHODS: Five focus groups involving 39 black men and women (aged > or =18 years) were conducted at State University of New York (SUNY) Downstate Medical Center in Brooklyn to ascertain barriers preventing or delaying OSA evaluation and treatment. RESULTS: Misconceptions about sleep apnea were a common theme that emerged from participants' responses. Obstructive sleep apnea was often viewed as a type of insomnia, an age-related phenomenon, and as being caused by certain bedtime activities. The major theme that emerged about barriers to OSA evaluation was unfamiliarity with the study environment. Barriers were categorized as: problems sleeping in a strange and unfamiliar environment, unfamiliarity with the study protocol, and fear of being watched while sleeping. Barriers to continuous positive airway pressure (CPAP) treatment adoption were related to the confining nature of the device, discomfort of wearing a mask while they slept, and concerns about their partner's perceptions of treatment. CONCLUSION: Results of this study suggest potential avenues for interventions to increase adherence to recommended evaluation and treatment of OSA. Potential strategies include reducing misconceptions about OSA, increasing awareness of OSA in vulnerable communities, familiarizing patients and their partners with laboratory procedures used to diagnose and treat OSA. We propose that these strategies should be used to inform the development of culturally and linguistically tailored sleep apnea interventions to increase awareness of OSA among blacks who are at risk for OSA and associated comorbidities.

Sex-related differences in clinical outcomes among patients with myocardial infarction with nonobstructive coronary artery disease: A systematic review and meta-analysis.

BACKGROUND: Among patients who present with acute myocardial infarction (MI), 2-6% are found to have non-obstructive coronary arteries (NOCA). Patients with MINOCA are more commonly women and present at a younger age (51-59 years). The influence of sex on adverse event rates remains unclear. METHODS: PubMed, MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), EMBASE, EBSCO, Web of Science and CINAHL databases were searched for trials comparing gender differences in clinical outcomes among patients with MINOCA from inception through April 10, 2022. The primary endpoint of the study was composite major adverse clinical events (MACE) including all-cause mortality, non-fatal MI, stroke, and cardiovascular readmissions, and secondary endpoints were the individual components of the MACE. RESULTS: Seven studies with a total of 28,671 MINOCA patients were included (n = 11,249 men and n = 17,422 women) over a mean follow-up of 2 years. Women had more MACE than men (10.1% vs. 9.1%, OR 1.15, 1.04-1.23, I2 = 44.7%). Among secondary endpoints, only the incidence of stroke was higher in women (3.5% vs. 2.2%, OR 1.3, 1.01-1.68, I2 = 0%). All-cause mortality, non-fatal MI, and cardiovascular readmissions were not significantly different between the two groups. CONCLUSIONS: We hypothesize that small vessel disease associated with MINOCA drives MACE in women and the diminishing influence of estrogen, hypercoagulability and underprescribing could contribute to the differences sex-related outcomes.

Association between ideal cardiovascular health and markers of subclinical cardiovascular disease.

BACKGROUND: Ideal cardiovascular health (CVH) was proposed by the American Heart Association to promote population health. We aimed to characterize the association between ideal CVH and markers of subclinical cardiovascular disease (CVD). HYPOTHESIS: We hypothesized that ideal CVH is associated with several markers of subclinical CVD. METHODS: We used data from the Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) study. We assigned 1 for each of the ideal CVH factors met. Endothelial function, expressed as Framingham reactive hyperemia index (fRHI), was measured using the EndoPAT device. Coronary artery calcium (CAC) and carotid intima-media thickness (CIMT) were quantified using electron beam computed tomography and carotid ultrasonography, respectively. RESULTS: A total of 1933 participants (mean [SD] age: 59 [7.5] years, 34% male, 44% black) were included. The mean number of ideal CVH factors met was 2.3 ± 1.3, with blacks having significantly lower score compared to whites (2.0 ± 1.2 vs 2.5 ± 1.4, respectively; P < 0.001). Seven hundred and eighty-nine participants (41%) achieved ≥3 ideal CVH factors. Participants with ≥3 ideal CVH factors (compared to those with <3 factors) had an average of 107 (95% confidence interval [CI]: 50-165) Agatston units lower CAC, 0.04 (0.01-0.06) mm lower CIMT, and 0.07 (0.02-0.12) units higher fRHI, after adjusting for age, sex, race, income, education, and marital status. Participants with ≥3 ideal CVH factors had 50% lower odds (95% CI: 28%-66%) of having CAC >100 Agatston units. CONCLUSION: In a community-based study with low prevalence of ideal CVH, even achieving three or more ideal CVH factors were associated with lower burden of subclinical CVD, indicating the utility of this construct for disease prevention.

Contrast-induced acute kidney injury in interventional cardiology: Emerging evidence and unifying mechanisms of protection by remote ischemic conditioning.

Contrast-induced acute kidney injury (CI-AKI) is a common complication of many diagnostic and therapeutic cardiovascular procedures. It is associated with longer in-hospital stay, more complicated hospitalization course, and higher in-hospital morbidity and mortality. With increasing use of contrast media in various diagnostic and interventional procedures, the prevalence of CI-AKI is expected to rise. Although pre-hydration with intravenous normal saline is recommended in patients with elevated risk of CI-AKI, this approach is often not feasible in many clinical settings. Remote ischemic conditioning (RIC), elicited by application of one or more, brief, non-injurious episodes of ischemia and reperfusion of a limb, is a promising therapy for preventing or attenuating the deleterious effects of contrast media on the kidney. Although the mechanisms of protection by RIC have not been completely defined, complex humoral, neural, and inflammatory pathways have been hypothesized to be in play. Given that RIC is non-invasive and cheap, it is attractive from clinical and economic perspective as a therapy to protect the kidney from CI-AKI. In this succinct review, we highlight the unifying mechanisms of CI-AKI and provide an overview of proposed biological mechanisms of renal protection by RIC. Emerging pre-clinical and clinical evidence in interventional cardiology is also discussed.