Multicenter evaluation of stress-first myocardial perfusion image triage by nuclear technologists and automated quantification.

BACKGROUND: A stress-first myocardial perfusion imaging (MPI) protocol saves time, is cost effective, and decreases radiation exposure. A limitation of this protocol is the requirement for physician review of the stress images to determine the need for rest images. This hurdle could be eliminated if an experienced technologist and/or automated computer quantification could make this determination. METHODS: Images from consecutive patients who were undergoing a stress-first MPI with attenuation correction at two tertiary care medical centers were prospectively reviewed independently by a technologist and cardiologist blinded to clinical and stress test data. Their decision on the need for rest imaging along with automated computer quantification of perfusion results was compared with the clinical reference standard of an assessment of perfusion images by a board-certified nuclear cardiologist that included clinical and stress test data. RESULTS: A total of 250 patients (mean age 61 years and 55% female) who underwent a stress-first MPI were studied. According to the clinical reference standard, 42 (16.8%) and 208 (83.2%) stress-first images were interpreted as "needing" and "not needing" rest images, respectively. The technologists correctly classified 229 (91.6%) stress-first images as either "needing" (n = 28) or "not needing" (n = 201) rest images. Their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 66.7%, 96.6%, 80.0%, and 93.5%, respectively. An automated stress TPD score ≥1.2 was associated with optimal sensitivity and specificity and correctly classified 179 (71.6%) stress-first images as either "needing" (n = 31) or "not needing" (n = 148) rest images. Its sensitivity, specificity, PPV, and NPV were 73.8%, 71.2%, 34.1%, and 93.1%, respectively. In a model whereby the computer or technologist could correct for the other's incorrect classification, 242 (96.8%) stress-first images were correctly classified. The composite sensitivity, specificity, PPV, and NPV were 83.3%, 99.5%, 97.2%, and 96.7%, respectively. CONCLUSION: Technologists and automated quantification software had a high degree of agreement with the clinical reference standard for determining the need for rest images in a stress-first imaging protocol. Utilizing an experienced technologist and automated systems to screen stress-first images could expand the use of stress-first MPI to sites where the cardiologist is not immediately available for interpretation.

Vitamin D therapy in individuals with prehypertension or hypertension: the DAYLIGHT trial.

BACKGROUND: A large body of epidemiological and experimental evidence suggests that vitamin D deficiency may promote hypertension. This raises the possibility that vitamin D supplementation could be a simple intervention to reduce blood pressure, but data from prospective, randomized trials are limited. METHODS AND RESULTS: A double-blind, randomized, controlled trial was conducted at 4 sites in the United States. We enrolled 534 individuals 18 to 50 years of age with low vitamin D status (25-hydroxyvitamin D levels ≤25 ng/mL) and systolic blood pressure of 120 to 159 mm Hg. Participants were randomized to high-dose (4000 IU/d) versus low-dose (400 IU/d) oral vitamin D3 for 6 months. The primary end point was change in mean 24-hour systolic blood pressure. Secondary end points included change in ambulatory diastolic blood pressure and clinic systolic and diastolic blood pressures. The median age was 38 years, and 62% of participants were men. Forty-six percent of participants were white, and 48% were black. The median 25-hydroxyvitamin D level at baseline was 15.3 ng/mL. Four-hundred fifty-five participants (85%) had at least 1 follow-up blood pressure measurement; 383 participants (72%) completed the full 6-month study. At the end of the study, there was no significant difference in the primary end point (change in mean 24-hour systolic blood pressure, -0.8 versus -1.6 mm Hg in the high-dose and low-dose arms; P=0.71) or in any of the secondary end points. Furthermore, there was no evidence of association between change in 25-hydroxyvitamin D and change in 24-hour systolic blood pressure at 6 months (Spearman correlation coefficient, -0.05, P=0.34). Results were consistent across prespecified subgroups. CONCLUSIONS: Vitamin D supplementation did not reduce blood pressure in individuals with prehypertension or stage I hypertension and vitamin D deficiency. Our findings suggest that the association between vitamin D status and elevated blood pressure noted in observational studies is not causal. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01240512.

Caseous Calcification of Mitral Annulus: A Rare Monster Leading to Cerebrovascular Accident.

Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification that maybe easily misdiagnosed or confused with an abscess, a tumor, or infective vegetation. The main pathophysiological mechanism leading to CCMA involves degeneration and calcium deposition on the mitral valve. We present a case of CCMA to help understand this clinical entity.

Broken lung and broken heart: a case of right pneumothorax resulting in Takotsubo cardiomyopathy.

Takotsubo cardiomyopathy (TC), also known as broken-heart syndrome, is usually the result of a stressful event. It is more common in postmenopausal females and can mimic an acute coronary syndrome. We report the case of an elderly female who presented with acute chest pain and ECG changes suggestive of an acute myocardial infarction, but later was found to have right-sided pneumothorax with TC. The case highlights the growing interest in stress cardiomyopathy and its variable modes of presentation. It also reminds us that the acute chest pain of a pneumothorax can closely mimic a coronary event with similar electrocardiographic changes.

A case report of deglutition triggered atrial fibrillation in a patient with Laing distal myopathy.

BACKGROUND: Deglutition-induced atrial fibrillation is a rare clinical entity with a reported prevalence of 0.6%. Laing distal myopathy is a rare autosomal dominant muscular dystrophy that is the result of mutations within the slow skeletal muscle fibre myosin heavy chain gene (MYH7). Atrial fibrillation has not been previously reported in patients with Laing distal myopathy. We describe the first reported case of deglutition triggered atrial fibrillation in a female with a history of Laing distal myopathy. CASE SUMMARY: A 44-year-old female with a history of Laing distal myopathy diagnosed at age 32, began experiencing intermittent episodes of pre-syncope and palpitations which occurred after deglutition with food. An ambulatory 30-day patient triggered event monitor recorded episodes of atrial fibrillation with rapid ventricular response. Family history was significant for Laing distal myopathy, atrial fibrillation, as well as sudden cardiac death. Laboratory data, transthoracic echocardiogram, cardiac magnetic resonance imaging, and an exercise treadmill SPECT Imaging stress test were normal. An oesophagram revealed a mild oesophageal dysmotility with no other abnormalities. She was started on flecainide 50 mg p.o. every 8 h and verapamil 40 mg p.o. every 8 h with no further episodes of atrial fibrillation. DISCUSSION: Given the strong genetic component of this myopathy, one could postulate as to a possible genetic component in the development of atrial fibrillation in our patient. Although we cannot make definite correlation between deglutition-induced atrial fibrillation and Laing myopathy, it is important to report this unusual association which has not been described before.

Vitamin D and cardiovascular disease risk: emerging evidence.

PURPOSE OF REVIEW: Vitamin D deficiency is common throughout the world, with a particularly high prevalence in northern latitudes and colder climates. Although the best known sequelae of vitamin D deficiency involve the musculoskeletal system, a growing body of evidence suggests that vitamin D status may influence cardiovascular health as well. This review focuses on recent studies linking vitamin D and cardiovascular disease risk, emphasizing the potential relevance to primary prevention. RECENT FINDINGS: There is strong experimental evidence that vitamin D status may influence cardiovascular structure and function. The number of clinical studies has steadily grown in recent years, with the largest number comprising observational studies showing associations between low vitamin D status, the presence of various cardiovascular risk factors, and adverse cardiovascular outcomes. A few small, randomized, controlled studies have been published, but these have been largely inconclusive. SUMMARY: Despite substantial clinical evidence linking vitamin D deficiency with increased cardiovascular risk, it remains to be established whether this represents a causal association. Further study is needed with prospective, randomized controlled trials before vitamin D supplementation can be routinely recommended for the primary or secondary prevention of cardiovascular disease.

Psychiatric history, post-discharge distress, and personality characteristics among incident female cases of takotsubo cardiomyopathy: A case-control study.

BACKGROUND: The role of psychological factors in the onset of takotsubo cardiomyopathy (TC) is still controversial. Associations with previous psychiatric conditions are registry-based; associations with personality characteristics and psychological sequelae of TC have been largely unexplored. This case-control study sought to study pre-admission psychiatric morbidity, personality traits, and post-discharge distress in incident cases of TC. METHODS: TC cases (Mayo clinic criteria) and acute myocardial infarction (MI) controls were recruited among women admitted to two Emergency Departments in New England. Healthy controls (HC) were recruited from a volunteers' registry. Preadmission psychiatric history (DSM-IV-TR) was abstracted from the medical record. PTSD symptoms (Impact of Events Scale); distress (Hospital Anxiety and Depression Scale); perceived stress (PS scale) and personality traits (optimism; hostility, type D personality) were collected via phone interview one month after discharge. RESULTS: From March 2013 through October 2015, 107 participants (45 TC, 32 MI and 30 HC) were enrolled. The prevalence of preadmission anxiety disorders was 24.4% in TC, 9.4% in MI, and 0 in HC (p = 0.007) while that of mood disorders was similar across groups. TC had higher psychological distress, perceived stress, and PTSD symptoms post-discharge vs. MI and HC. In adjusted models, PTSD symptoms remained higher in TC vs. MI (b = 0.55, p < 0.05) and vs. HC (b = 0.92, p < 0.01). Optimism and hostility scores were similar across groups, while type D (social inhibition) scores were higher in TC and MI vs. HC. CONCLUSIONS: Preadmission anxiety, but not depression, was associated with the occurrence of TC. High distress and PTSD symptoms post-discharge indicate that TC women may be at risk for poor psychological adjustment.

Reproductive History of Women With Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TC) occurs predominantly in postmenopausal women, suggesting a possible role of reproductive and hormonal factors in the pathophysiology of this condition. Yet reproductive characteristics of women with TC have received limited attention. This prospective case-control study sought to explore reproductive characteristics associated with TC. Incident TC cases and myocardial infarction (MI) controls were recruited among consecutive women presenting at the emergency departments of 2 large medical centers in Massachusetts and Connecticut. Female healthy controls were recruited from a registry of research volunteers. Information about reproductive history was collected 1 month after discharge using standardized questionnaires completed during phone interviews. Linear and logistic regression models were used to estimate associations with reproductive factors. From March 2013 to October 2015, 209 women were screened for eligibility and 107 (45 TC, 32 MI, and 30 healthy controls) were enrolled. Conditions uniquely associated with TC were a history of irregular menses (adjusted OR, TC vs MI 8.30; 95% CI 1.01 to 69.18), number of pregnancies (adjusted ß coefficient 0.69; SE 0.35, p = 0.05), and use of post-menopausal hormone replacement therapy (OR 5.79; CI 1.20 to 28.02). We did not find associations with history of infertility, breastfeeding, hysterectomy or oophorectomy, oral contraceptive use, and age at menopause. In conclusion, our findings suggest that premenopausal reproductive factors may play an important role in the onset of TC at a later age. These results need to be confirmed in future studies with larger populations.

High-Dose versus Low-Dose Vitamin D Supplementation and Arterial Stiffness among Individuals with Prehypertension and Vitamin D Deficiency.

INTRODUCTION: Vitamin D deficiency is associated with the onset and progression of hypertension and cardiovascular disease (CVD). However, mechanisms underlying vitamin D deficiency-mediated increased risk of CVD remain unknown. We sought to examine the differential effect of high-dose versus low-dose vitamin D supplementation on markers of arterial stiffness among ~40 vitamin D deficient adults with prehypertension. METHODS: Participants were randomized to high-dose (4000 IU/d) versus low-dose (400 IU/d) oral vitamin D3 for 6 months. 24 hr ambulatory blood pressure (BP), carotid-femoral pulse wave velocity, and pulse wave analyses were obtained at baseline and after 6 months of vitamin D supplementation. RESULTS: There were no changes in resting BP or pulse wave velocity over 6 mo regardless of vitamin D dose (all p > 0.202). High-dose vitamin D decreased augmentation index and pressure by 12.3 ± 5.3% (p = 0.047) and 4.0 ± 1.5 mmHg (p = 0.02), respectively. However, these decreases in arterial stiffness were not associated with increases in serum 25-hydroxyvitamin D over 6 mo (p = 0.425). CONCLUSION: High-dose vitamin D supplementation appears to lower surrogate measures of arterial stiffness but not indices of central pulse wave velocity. Clinical Trial Registration. This trial is registered with www.clinicaltrials.gov (Unique Identifier: NCT01240512).