Previously undiagnosed angina pectoris in individuals without established cardiovascular disease: Prevalence and prognosis in the United States.

BACKGROUND: The prevalence and prognosis of previously undiagnosed angina pectoris (AP) in the absence of established cardiovascular disease (CVD) are unknown. This study sought to determine the prevalence and prognosis of previously undiagnosed AP in the absence of established CVD in the United States. METHODS: Data derived from the National Health and Nutrition Examination Survey (2001-2018) and the Rose Angina Questionnaire (RAQ) were used to identify AP among participants ≥ 40 years without established CVD. Determinants of previously undiagnosed AP (AP undiagnosed prior to RAQ analysis) and predictors of all-cause mortality were identified using multivariable logistic regression analysis and the Cox proportional hazard model. RESULTS: Of the 27,506 participants eligible for analysis, 621 participants had previously undiagnosed AP. Thus, the prevalence of previously undiagnosed AP was 1.99% (95% CI 1.79-2.20). Female gender, poverty, < high school education, hypertension, cigarette smoking, and obesity were independent predictors of previously undiagnosed AP. All-cause mortality rates were 1.71 per 1000 person months for participants with previously undiagnosed AP and were 1.08 per 1000 person months to those without previously undiagnosed AP (p = 0.003). CONCLUSIONS: The prevalence of previously undiagnosed AP in the United States is 1.99% in persons ≥ 40 years of age without established CVD. Previously undiagnosed AP in those without established CVD was an independent predictor of all-cause mortality.

Comparative feasibility of dobutamine stress echocardiography performed with and without intravenous contrast in patients with class III obesity.

BACKGROUND: Concern exists regarding adequacy of visualization of stress echocardiograms performed without intravenous contrast in persons with Class III obesity (body mass index ≥ 40 kg/m2 ). METHODS: Dobutamine stress echocardiography (DSE) was performed on 128 candidates for bariatric surgery with class III obesity without chest pain or pre-existent coronary artery disease (CAD). DSE without intravenous contrast was initially performed on 62 patients with class III obesity, then was subsequently was performed with intravenous contrast on 66 patients with class III obesity. Left ventricular (LV) regional wall motion was assessed at baseline and peak stress using the 16-segment model. RESULTS: In the intravenous contrast group, 1046 of 1056 LV segments studied (99.1%) were well-visualized and interpretable at baseline and 1044 of 1056 LV segments studied (98.9%) were well-visualized and interpretable at peak stress. In the non-contrast group, 905 of 992 segments studied (91.2%) were well-visualized and interpretable at baseline and 886 of 992 segments studied (89.3%) were well-visualized and interpretable at peak stress. A significantly greater number of LV segments were well-visualized and interpretable in the intravenous contrast group than in the group compared to the non-contrast group, at baseline and at peak stress (p < 0.00001 for both). DSE was positive for ischemia in one patient. All patients underwent bariatric surgery without cardiovascular complications. Six months after surgery, all patients were alive; none developed cardiovascular events. CONCLUSION: The use of intravenous contrast during DSE significantly improves visualization and interpretability of LV segments in patients with class III obesity.

Human Laterality Disorders: Pathogenesis, Clinical Manifestations, Diagnosis, and Management.

Human laterality disorders comprise a group of diseases characterized by abnormal location (situs) and orientation of thoraco-abdominal organs and vessels across the left-right axis. Situs inversus totalis is mirror image reversal of thoraco-abdominal organs/great vessels. Situs ambiguus, better known as heterotaxy, is abnormal arrangement of thoraco-abdominal organs across the left-right axis excluding situs inversus totalis. Heterotaxy, also referred to as atrial or atrial appendage isomerism, is characterized by abnormal location of left-sided or right-sided organs with loss of asymmetry of normally paired asymmetric organs. It is associated with a variety of anomalies involving the heart, great vessels, lungs and intra-abdominal organs. Right and left atrial isomerism are associated with multiple complex congenital cardiac and vascular anomalies, many of which are lethal when untreated. Isomerism may also affect the lungs, spleen, liver, gall bladder, and intestines. Innovative surgical therapy of heterotaxy/isomerism has reduced early mortality and markedly improved long-term prognosis.

Mechanical Circulatory Support Prior to Heart Transplantation Predicts Early Post-Operative Stroke.

BACKGROUND: Mechanical circulatory support (MCS) devices are often deployed to treat patients with refractory cardiogenic shock, rapid deterioration of heart failure, and inotrope-dependent patients. Stroke is a common complication of MCS therapy. This study assesses the risk of stroke during the early post-heart transplantation (HT) period (days from successful HT to discharge or death) in patients who received MCS therapy leading to HT. METHODS: Data were derived from the United Organ Sharing (UNOS) database. MCS modalities studied include left ventricular assist devices (LVAD), right ventricular assist devices (RVAD), biventricular ventricular assist devices (BiVAD), and extra-corporeal membrane oxygenation (ECMO). A multiple logistic regression model was used to determine the risk of stroke during the early post-HT period associated in patients treated with MCS leading to HT. RESULTS: Between 1988 and 2014, 10,258 patients received MCS therapy leading to HT. Of these, 160 patients (1.96%) developed stroke during the early post-HT period. Multiple regression analysis showed that MCS modalities and associated odds ratios for early post-HT stroke and associated 95% confidence intervals were as follows: LVAD (1.44, 0.70-2.94), RVAD (2.89, 1.03-8.05, BiVAD (3.24, 1.15-9.10), ECMO (2.27 (1.17-4.40), and any MCS (1.60 (1.20-2.12). CONCLUSIONS: With the exception of left ventricular assist devices, use of MCS modalities leading to HT is significantly and independently associated with stroke during the early post-HT period.

Obesity and Coronary Heart Disease: Epidemiology, Pathology, and Coronary Artery Imaging.

Overweight and obesity contribute to the development of cardiovascular disease (CVD) in general and coronary heart disease (CHD) in particular in part by their association with traditional and nontraditional CVD risk factors. Obesity is also considered to be an independent risk factor for CVD. The metabolic syndrome, of which central obesity is an important component, is strongly associated with CVD including CHD. There is abundant epidemiologic evidence of an association between both overweight and obesity and CHD. Evidence from postmortem studies and studies involving coronary artery imaging is less persuasive. Recent studies suggest the presence of an obesity paradox with respect to mortality in persons with established CHD. Physical activity and preserved cardiorespiratory fitness attenuate the adverse effects of obesity on CVD events. Information concerning the effect of intentional weight loss on CVD outcomes in overweight and obese persons is limited.

Effect of ICD implantation on cardiovascular outcomes in patients with cardiac amyloidosis: A systematic review and meta-anaylsis.

INTRODUCTION: Cardiac amyloidosis is associated with a high rate of sudden cardiac death (SCD). Whether implantable cardioverter-defibrillator (ICD) use in such patients prevents SCD is uncertain. This study assesses outcomes of ICD use in patients with cardiac amyloidosis. METHODS: A systematic review and meta-analysis of data were performed after searching multiple databases and scientific sites pertaining to ICD use and cardiac amyloidosis. Of 8260 citations identified, six studies comprising 194 patients met inclusion criteria. RESULTS: Mean values and frequencies of patient characteristics were as follows: mean NT-proBNP: 6867.9 pg/mL, mean left ventricular ejection fraction: 48.1%, heart failure: 67%, nonsustained ventricular tachycardia: 51%, syncope: 21%, and secondary prevention: 33%. During the mean follow-up period of 18.21 months, 18% of patients received appropriate ICD treatment and 5% received inappropriate ICD treatment. The mortality rate was 31%. Two studies assessed the difference between patients with appropriate ICD treatment and patients with absence of appropriate ICD treatment. There was no difference between the two groups when stratified on multiple selected third variables except for two subgroups. Male gender was associated with a higher rate of appropriate ICD treatment, whereas New York Heart Association class III or IV heart failure patients was associated with a lower rate of appropriate ICD treatment. CONCLUSION: The frequency of appropriate ICD treatment in cardiac amyloidosis is low and is not predicted by nonsustained ventricular tachycardia. Male gender is associated with appropriate ICD treatment. New York Heart Association class III or IV heart failure is associated with lower rate of appropriate ICD treatment.

Outcomes and Hospital Utilization in Patients With Papillary Muscle Rupture Associated With Acute Myocardial Infarction.

Papillary muscles rupture (PMR) is a rare complication of acute myocardial infarction (MI) that can lead to severe hemodynamic compromise, acute heart failure, and death. This study was designed to assess demographics, outcomes, and hospital utilization trends in the management of PMR associated with acute MI. Data were derived from the National Inpatient Sample for the years 2005 to 2014. ICD-9 codes 410.0 to 410.9 were used to identify patients with acute MI. ICD-9 code 429.6 was used to identify patients with PMR. ICD-9 procedures codes 35.23, 35.24, and 35.12 were used to identify patients who underwent mitral valve replacement (MVR) or repair. Of the 3,244,799 admissions, 932 were complicated by PMR (incidence of 0.029%). The majority of patients with PMR were ≥65 years old (60.1%) and male (60.4%). Of those with PMR, 57.5% underwent MVR. Compared to patients without PMR, those with PMR had a significantly higher in-hospital mortality rate (5.3 vs 36.3%, p <0.001), cost of hospitalization ($20,205 vs $74,383, p <0.001) and length of hospital stay (4.67 ± 02 vs 11.2 ± 0.80 days, p <0.001). Predictors of in-hospital mortality in PMR patients were age, inferior wall acute MI, and cardiac arrest. Predictors of MVR in PMR patients were age, female gender, concomitant coronary artery bypass grafting, mechanical circulatory support, longer length of stay, and admission to a large hospital. In conclusion, patients with PMR associated with acute MI have higher risk of in-hospital mortality, greater cost of hospitalization and longer length of stay than patients acute MI without PMR.

Non-infectious aortic and mitral valve vegetations in a patient with eosinophilic granulomatosis with polyangiitis.

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of vasculitis characterised by atopic manifestations, inflammation of small-sized to medium-sized arteries and veins, hypereosinophilia and tissue infiltration with eosinophils. Cardiac complications occur most commonly in the absence of antineutrophil cytoplasmic antibodies. Cardiac complications include coronary arteritis (rare), pericarditis, myocarditis, endocardial fibrosis (Loeffler's endocarditis) and intracavitary thrombosis of the left or right ventricle. This is the first reported case of large non-infectious valvular vegetations associated with EGPA.

Impact of Left Ventricular Hypertrophy on Peak Serum Troponin T Levels in Patients With Acute Myocardial Infarction.

Previous studies have reported that peak serum troponin I levels were disproportionately elevated in patients with acute anterior ST-segment elevation myocardial infarction (STEMI) and left ventricular (LV) hypertrophy (LVH) compared with those with normal LV mass. The purpose of this retrospective study was to assess the relation of peak serum troponin T levels in patients with normal LV mass and in subjects with mild, moderate, and severe LVH in patients with acute STEMI or non-ST segment elevation myocardial infarction (NSTEMI) when stratified on variables that might be expected to affect serum troponin T levels. The study population consisted of 262 patients; 91 with STEMI and 161 with NSTEMI. Serum troponin levels and 2-dimensional echocardiograms were obtained within the first 24 hours of hospitalization for STEMI or NSTEMI. There was no significant difference in serum troponin T levels in LV mass and/or LVH groups (p = 0.3210). There was no significant difference in serum troponin T levels in LV mass and/or LVH groups when these data were stratified on third variables including serum creatinine >1.2 mg/dl (p = 0.3681), LV ejection fraction <60% (p = 0.0978), STEMI (p = 0.2576), NSTEMI (p = 0.4994), and location of severe coronary stenosis (p = 0.1981). The results of this study suggest that there is no association between peak serum troponin T levels and LV mass and/or LVH groups when such groups are stratified on a third variable that may influence peak serum troponin T levels.

Cardiovascular Effects of Drugs Used to Treat Attention-Deficit/Hyperactivity Disorder Part 2: Impact on Cardiovascular Events and Recommendations for Evaluation and Monitoring.

A variety of psychostimulant and nonpsychostimulant medications have proven to be successful in reducing inattention, impulsivity, and hyperactivity in individuals with attention-deficit/hyperactivity disorder (ADHD). Psychostimulants used to treat ADHD include methylphenidate and related drugs and various amphetamine preparations. Nonpsychostimulant medications used to treat ADHD include atomoxetine and 2 α-2 adrenergic agonists: guanfacine extended-release and clonidine extended-release. The psychostimulants and atomoxetine have been shown, on average, to increase heart rate by 3-10 beats/min, systolic blood pressure by 3-8 mm Hg, and diastolic BP by 2-14 mm Hg. These drugs may also delay ventricular repolarization. The α-2 adrenergic agonists may reduce heart rate and BP. For these reasons, there is concern about the safety of psychostimulant and nonpsychostimulant medications in patients with ADHD. Studies in healthy children adolescents and adults have not consistently shown a disproportionately high risk of major adverse cardiovascular (CV) outcomes, including sudden unexpected death. Those with underlying CV disease have, in general, tolerated these drugs well. Certain high-risk groups have been identified who may benefit from cardiology consultation prior to drug initiation. Several American and Canadian professional societies have published guidelines for CV evaluation, management, and monitoring of patients with ADHD who are candidates for pharmacotherapy.

Cardiovascular Effects of Drugs Used to Treat Attention-Deficit/Hyperactivity Disorder: Part 1: Epidemiology, Pharmacology, and Impact on Hemodynamics and Ventricular Repolarization.

Attention-deficit/hyperactivity disorder (ADHD) is a clinical syndrome characterized by persistent inattention, impulsivity, and hyperactivity. It is most commonly encountered in children and adolescents but may persist into adulthood. A variety of psychostimulant and nonpsychostimulant medications have proven to be successful in reducing inattention, impulsivity, and hyperactivity in those with ADHD. Psychostimulants used to treat ADHD include methylphenidate and related drugs and various amphetamine preparations. Non-psychostimulant medications used to treat ADHD include atomoxetine and two alpha-2 adrenergic agonists: guanfacine extended-release and clonidine extended-release. The psychostimulants and atomoxetine have been shown, on average, to increase heart rate by 3-10 beats/min, systolic blood pressure by 3-8 mm Hg, and diastolic blood pressure by 2-14 mm Hg. These drugs may also delay ventricular repolarization. The alpha-2 adrenergic agonists may reduce heart rate and blood pressure. For these reasons, there is concern about the safety of psychostimulant and nonpsychostimulant medications in patients with ADHD. In part 1 of this review, we discuss the epidemiology and natural history of ADHD, describe the pharmacology of drugs used to treat ADHD, and discuss in detail studies assessing the effects of ADHD drugs on blood pressure, heart or pulse rate, and electrocardiographic indices of ventricular repolarization.

Reprint of: Healthy Weight and Obesity Prevention: JACC Health Promotion Series.

Overweight and obesity have reached epidemic levels in the United States and worldwide, and this has contributed to substantial cardiovascular and other health risks. However, controversy exists concerning the causes of obesity and effective modalities for its prevention and treatment. There is also controversy related to the concept of metabolically healthy obesity phenotype, the "obesity paradox," and on the importance of fitness to protect individuals who are overweight or obese from cardiovascular diseases. In this state-of-the-art review, the authors focus on "healthy weight" with the emphasis on the pathophysiologic effects of weight gain on the cardiovascular system; mechanistic/triggering factors; and the role of preventive actions through personal, education/environment, and societal/authoritative factors, as well as factors to provide guidance for caregivers of health promotion. Additionally, the authors briefly review metabolically healthy obesity, the obesity paradox, and issues beyond lifestyle consideration for weight loss with medications and bariatric surgery.

Third-degree burns associated with transcutaneous pacing.

A 69-year-old severely obese diabetic woman developed nausea, vomiting and diarrhoea which caused multiple metabolic alterations leading to hypotension and bradycardia due to slow atrioventricular junctional rhythm. Transcutaneous pacing (TCP) was initiated and maintained until the underlying heart rate and blood pressure normalised. TCP gel pads were kept in place prophylactically after pacing was terminated. Gel pads remained attached to the anterior thorax and back for a total of 36 hours. During this time the patient developed third-degree burns at the side of gel pad attachment. With appropriate wound care and after a long hospitalisation, the patient was discharged in stable condition. This case demonstrates that prolonged use of TCP gel pads without frequent replacement may lead to third-degree burns. It also suggest that prophylactic use of TCP gel pads should be avoided.

Healthy Weight and Obesity Prevention: JACC Health Promotion Series.

Overweight and obesity have reached epidemic levels in the United States and worldwide, and this has contributed to substantial cardiovascular and other health risks. However, controversy exists concerning the causes of obesity and effective modalities for its prevention and treatment. There is also controversy related to the concept of metabolically healthy obesity phenotype, the "obesity paradox," and on the importance of fitness to protect individuals who are overweight or obese from cardiovascular diseases. In this state-of-the-art review, the authors focus on "healthy weight" with the emphasis on the pathophysiologic effects of weight gain on the cardiovascular system; mechanistic/triggering factors; and the role of preventive actions through personal, education/environment, and societal/authoritative factors, as well as factors to provide guidance for caregivers of health promotion. Additionally, the authors briefly review metabolically healthy obesity, the obesity paradox, and issues beyond lifestyle consideration for weight loss with medications and bariatric surgery.

Obesity and Cardiac Remodeling in Adults: Mechanisms and Clinical Implications.

Obesity, particularly severe obesity is capable of producing hemodynamic alterations that contribute to changes in cardiac morphology which may predispose to impairment of ventricular function and heart failure. These include a high cardiac output state in most, left ventricular (LV) hypertrophy, and LV diastolic dysfunction. Right heart involvement may result from LV failure, the hypercirculatory state, and sleep disordered breathing. In recent years experimental studies and some studies in humans suggest that certain neurohormonal and metabolic alterations that occur commonly in obesity may contribute to alterations in cardiac structure and function. These include activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, hyperleptinemia due to leptin resistance, low circulating adiponectin levels, insulin resistance with hyperinsulinemia, and possibly cardiac lipotoxicity. This review will describe the ways in which these factors weave together to promote adaptations and maladaptations that result in alterations in cardiac structure and function which may contribute to the development of heart failure.

A QS pattern in leads V1 and V2 is associated with septal scarring independent of scar etiology - A cardiac magnetic resonance imaging study.

BACKGROUND: Isolated septal myocardial infarction (MI) is traditionally characterized by the presence of pathological Q waves in leads V1 and V2 on the surface electrocardiogram (ECG). The purpose of this study was to determine the relation between this ECG pattern and septal scar on cardiac magnetic resonance (CMR) imaging. METHODS: We retrospectively reviewed the medical records of 996 consecutive patients who received both ECG and CMR. RESULTS: Nineteen patients had a Q wave in leads V1 and V2. Septal scar was present in all 19 patients. Based on CMR imaging criteria, septal scars were ischemic in 8 patients (42%) and non-ischemic in 11 patients (58%). CONCLUSION: The results suggest that the presence of a QS pattern in leads V1 and V2 on the surface ECG is highly predictive of the presence of a septal myocardial scar, but is not diagnostic for septal MI, even after excluding comorbidities known to produce a pseudo-septal MI pattern.

Obesity and Ventricular Repolarization: a Comprehensive Review.

Obesity is known to be a strong predictor of sudden cardiac death. For this reason, concern exists that this association may be related to delayed ventricular repolarization (VR), which has been extensively studied in overweight and obese patients. The corrected QT interval (QTc) and QT or QTc dispersion have been the most commonly-used electrocardiographic methods for assessing VR. Multiple controlled studies demonstrated that QTc and QT or QTc dispersion were significantly longer/greater in overweight and obese subjects than in normal weight controls. The preponderance of evidence indicates that weight loss in overweight and obese patients, whether achieved by diet or bariatric surgery, significantly shortens QTc and decreases QT or QTc dispersion. Several co-morbidities that are commonly associated with obesity may delay VR. These include diabetes mellitus, the metabolic syndrome, systemic hypertension, left ventricular hypertrophy, heart failure, and obstructive sleep apnea. It is unclear whether overweight and obesity are independent predictors of delayed VR. It is also uncertain whether prolongation of QTc in such patients is sufficient to predispose to potentially fatal ventricular arrhythmias.

Management of cardiovascular diseases in patients with obesity.

The management of cardiovascular diseases (CVD) in patients with obesity presents numerous challenges. Obesity has a negative effect on almost all of the major CVD risk factors, and adversely influences cardiovascular structure and function. Patients who are overweight or obese have a higher incidence of almost all CVDs compared with patients who are of normal weight. However, those who are overweight or obese seem to have a better short-term and medium-term prognosis after major CVD events and interventional procedures or cardiac surgeries than leaner patients, a phenomenon termed the 'obesity paradox'. In considering the mechanisms underlying this paradox, we review evidence of the deleterious consequences of obesity in patients with coronary heart disease, and the limited data on the benefits of weight loss in patients with CVD. Additional studies are needed on the efficacy of purposeful weight loss on cardiovascular outcomes to determine the ideal body composition for patients with CVD.