Disparities in Revascularization After ST Elevation Myocardial Infarction (STEMI) Before and After the 2002 IOM Report.

OBJECTIVES: To examine nationwide trends for racial disparities in Percutaneous Coronary Intervention after ST elevated Myocardial Infarction (STEMI). BACKGROUND: The Institute of Medicine (IOM) report published in 2002 showed that African Americans were less likely to receive coronary revascularization such as CABG and stents even after controlling for socioeconomics. It recommended increased awareness of these disparities among health professionals to reduce this. We hypothesized that increased awareness of disparities since this report would have translated to reduction in racial disparities in percutaneous coronary intervention. METHODS: A retrospective analysis was conducted using data from the Agency of Healthcare Research and Quality's (AHRQ) National Inpatient Sample (NIS) 1998-2007. All patients with STEMI during this period were identified. The proportion that received Percutaneous Coronary Intervention (PCI) during the incident admission was compared by different ethnicities over the time period. Multivariable regression for each year was conducted using Poisson regression with robust variances. The analysis controlled for gender, insurance status, co-morbidities, hospital bed size, location and teaching status. RESULTS: Based on the database, about 2.04 million patients were managed for acute Myocardial Infarction from 1998 to 2007, of these 938,176 had STEMI. The primary PCI rate after STEMI among Caucasians was 29.1%, African Americans-23.3% and Hispanics-28.3% [P < 0.001] On multivariate regression, compared to Caucasians, African Americans and Hispanics respectively were 26% (IRR = 0.74) and 16% (IRR = 0.84) less likely to receive PCI (both with P < 0.001) during the entire study period. CONCLUSION: Ethnic disparities in primary PCI after STEMI persist despite the 2002 IOM report.

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.

Demographic Determinants and Geographical Variability of COVID-19 Vaccine Hesitancy in Underserved Communities: Cross-sectional Study.

BACKGROUND: COVID-19 hospitalizations and deaths disproportionately affect underserved and minority populations, emphasizing that vaccine hesitancy can be an especially important public health risk factor in these populations. OBJECTIVE: This study aims to characterize COVID-19 vaccine hesitancy in underserved diverse populations. METHODS: The Minority and Rural Coronavirus Insights Study (MRCIS) recruited a convenience sample of adults (age≥18, N=3735) from federally qualified health centers (FQHCs) in California, the Midwest (Illinois/Ohio), Florida, and Louisiana and collected baseline data in November 2020-April 2021. Vaccine hesitancy status was defined as a response of "no" or "undecided" to the question "Would you get a coronavirus vaccine if it was available?" ("yes" categorized as not hesitant). Cross-sectional descriptive analyses and logistic regression models examined vaccine hesitancy prevalence by age, gender, race/ethnicity, and geography. The expected vaccine hesitancy estimates for the general population were calculated for the study counties using published county-level data. Crude associations with demographic characteristics within each region were assessed using the chi-square test. The main effect model included age, gender, race/ethnicity, and geographical region to estimate adjusted odds ratios (ORs) and 95% CIs. Interactions between geography and each demographic characteristic were evaluated in separate models. RESULTS: The strongest vaccine hesitancy variability was by geographic region: California, 27.8% (range 25.0%-30.6%); the Midwest, 31.4% (range 27.3%-35.4%); Louisiana, 59.1% (range 56.1%-62.1%); and Florida, 67.3% (range 64.3%-70.2%). The expected estimates for the general population were lower: 9.7% (California), 15.3% (Midwest), 18.2% (Florida), and 27.0% (Louisiana). The demographic patterns also varied by geography. An inverted U-shaped age pattern was found, with the highest prevalence among ages 25-34 years in Florida (n=88, 80.0%,) and Louisiana (n=54, 79.4%; P<.05). Females were more hesitant than males in the Midwest (n= 110, 36.4% vs n= 48, 23.5%), Florida (n=458, 71.6% vs n=195, 59.3%), and Louisiana (n= 425, 66.5% vs. n=172, 46.5%; P<.05). Racial/ethnic differences were found in California, with the highest prevalence among non-Hispanic Black participants (n=86, 45.5%), and in Florida, with the highest among Hispanic (n=567, 69.3%) participants (P<.05), but not in the Midwest and Louisiana. The main effect model confirmed the U-shaped association with age: strongest association with age 25-34 years (OR 2.29, 95% CI 1.74-3.01). Statistical interactions of gender and race/ethnicity with the region were significant, following the pattern found by the crude analysis. Compared to males in California, the associations with the female gender were strongest in Florida (OR=7.88, 95% CI 5.96-10.41) and Louisiana (OR=6.09, 95% CI 4.55-8.14). Compared to non-Hispanic White participants in California, the strongest associations were found with being Hispanic in Florida (OR=11.18, 95% CI 7.01-17.85) and Black in Louisiana (OR=8.94, 95% CI 5.53-14.47). However, the strongest race/ethnicity variability was observed within California and Florida: the ORs varied 4.6- and 2-fold between racial/ethnic groups in these regions, respectively. CONCLUSIONS: These findings highlight the role of local contextual factors in driving vaccine hesitancy and its demographic patterns.

Comparison among tomographic radionuclide ventriculography algorithms for computing left and right ventricular normal limits.

BACKGROUND: Various algorithms have been developed to compute right ventricular (RV) and left ventricular (LV) end-diastolic volumes, end-systolic volumes, and ejection fractions (EF) from tomographic radionuclide ventriculography (TRV). The aims of this investigation were to establish sex-specific normal limits, to determine whether different algorithms produce the same normal values, and to compare TRV normal limits vs for magnetic resonance imaging values in the literature. METHODS: Fifty-one healthy volunteers (29 men, 22 women) were studied prospectively. All subjects had normal electrocardiograms and echocardiographic examinations, and underwent both planar radionuclide ventriculography and TRV. Four algorithms were used to process TRV data. RESULTS: Normal limits for most functional parameters differed significantly from one algorithm to another. Volumes were greater in men, but no statistically significant differences were found between men and women for LV EF or RV EF values for any method. Normal LV and RV EF and volumes were largely consistent with the literature for cardiac magnetic resonance imaging. CONCLUSIONS: Ventricular measurements differ significantly among TRV algorithms. Therefore, it is important to apply sex-specific normal limits that are specific to a given TRV algorithm in interpreting LV and RV EF and volume measurements for each patient.

Transthyretin Cardiac Amyloidosis in Black Americans.

Transthyretin-related cardiac amyloidosis is a progressive infiltrative cardiomyopathy that mimics hypertensive and hypertrophic heart disease and often goes undiagnosed. In the United States, the hereditary form disproportionately afflicts black Americans, who when compared with whites with wild-type transthyretin amyloidosis, a phenotypically similar condition, present with more advanced disease despite having a noninvasive method for early identification (genetic testing). Although reasons for this are unclear, this begs to consider the inadequate access to care, societal factors, or a biological basis. In an effort to improve awareness and explore unique characteristics, we review the pathophysiology, epidemiology, and therapeutic strategies for transthyretin amyloidosis and highlight diagnostic pitfalls and clinical pearls for identifying patients with amyloid heart disease.

Augmentation of myocardial blood flow in hypertensive heart disease by angiotensin antagonists: a comparison of lisinopril and losartan.

OBJECTIVES: The goal of this study was to compare myocardial perfusion reserve (MPR) before and after long-term treatment with lisinopril and losartan in patients with hypertension and left ventricular hypertrophy (LVH). BACKGROUND: Studies have suggested that treatment with angiotensin-converting enzyme inhibitors (ACEIs) improves MPR in patients with hypertension by potentiating endogenous bradykinins. Because angiotensin receptor blockers (ARBs) lack a direct effect on bradykinins, we hypothesized that they may not improve MPR. METHODS: We measured pre- and post-treatment myocardial blood flow (MBF) by positron emission tomography in 17 patients (lisinopril: 9 patients, losartan: 8 patients) with hypertension and LVH at baseline and after coronary vasodilation with intravenous dipyridamole. In addition, we measured rest and hyperemic blood flow in eight normotensive controls. RESULTS: Post-treatment maximal coronary blood flow and MPR in the lisinopril group increased significantly compared with pretreatment values (3.5 +/- 1.2 vs. 2.6 +/- 1.1 ml/min/g, p = 0.02; 3.7 +/- 1.1 vs. 2.4 +/- 1 ml/min/g, respectively, p = 0.002, respectively). Post-treatment hyperemic flow in the patients treated with lisinopril was not significantly different from corresponding measurements in controls (3.5 +/- 1.2 vs. 3.9 +/- 1 ml/min/g, respectively, p = NS). In the patients treated with losartan, there was no difference between pre- and post-treatment MBF values and MPR. CONCLUSIONS: Myocardial perfusion reserve and maximal coronary flow improved in asymptomatic patients with hypertension-induced LVH after long-term treatment with lisinopril but not with losartan. Thus, ACEIs, but not ARBs, might be effective in repairing the coronary microangiopathy associated with hypertension-induced LVH.

Use of oral anticoagulants in African-American and Caucasian patients with atrial fibrillation: is there a treatment disparity?

Atrial fibrillation (AF) is a very common cardiac arrhythmia, and its prevalence is increasing along with aging in the developed world. This review discusses racial differences in the epidemiology and treatment of AF between African-American and Caucasian patients. Additionally, the effect of race on warfarin and novel oral anticoagulant use is discussed, as well as the role that physicians and patients play in achieving optimal treatment outcomes. Despite having a lower prevalence of AF compared with Caucasians, African-Americans suffer disproportionately from stroke and its sequelae. The possible reasons for this paradox include poorer access to health care, lower health literacy, and a higher prevalence of other stroke-risk factors among African-Americans. Consequently, it is important for providers to evaluate the effects of race, health literacy, access to health care, and cultural barriers on the use of anticoagulation in the management of AF. Warfarin-dose requirements vary across racial groups, with African-American patients requiring a higher dose than Caucasians to maintain a therapeutic international normalized ratio; the novel oral anticoagulants (dabigatran, rivaroxaban, and apixaban) seem to differ in this regard, although data are currently limited. Minority racial groups are not proportionally represented in either real-world studies or clinical trials, but as more information becomes available and other social issues are addressed, the treatment disparities between African-American and Caucasian patients should decrease.

Correlation of Prehypertension with Left Ventricular Mass Assessed by Cardiac Magnetic Resonance Imaging.

Introduction. The purpose of this observational cross-sectional study was to assess left ventricular mass (LVM) in prehypertensive individuals in comparison to normotensives and to determine if central blood pressure (BP) correlates better with LVM index (LVMI) than brachial BP. Methods and Result. Brachial and central BP measurements were completed at first visit and at 4 weeks in 65 healthy volunteers who were at least 40 years old and not on medication. Subjects were divided into two groups of normotensives and prehypertensives based on JNC-7 criteria and LVM was obtained using cardiac magnetic resonance imaging. Prehypertensives had significantly higher LVMI compared to normotensives (P < 0.01). Brachial and central BP also both positively correlate with LVMI (r = 0.460, P < 0.01; r = 0.318, P = 0.012, resp.) in both groups and neither method was superior to the other. After multivariate regression analysis and adjusting for cardiovascular risk factors, prehypertension remained an independent determinant of LVM. Conclusion. Prehypertension is associated with cardiovascular target organ damage, and central BP was not superior to brachial BP or vice versa for association with LVMI.

Right Atrial Myxoma and Syncope.

BACKGROUND: Right atrial myxoma accounts for 15-20% of cardiac myxomas and syncope is a very rare manifestation. We present the case of an 89-year-old man with right atrial myxoma and syncope, and discuss the role of cardiac magnetic resonance imaging (MRI) in the diagnosis of myxomas. CASE REPORT: An 89-year-old man with a history of hypertension, hyperlipidemia, chronic kidney disease stage 4, mild dementia, and benign prostatic hyperplasia presented to the emergency department with an episode of syncope. Physical examination demonstrated normal and regular heart sounds, and normal respiratory rate and oxygen saturation. Echocardiogram described a well-circumscribed echo-dense mass in the right atrial cavity, which was attached to the septum but not obstructing the tricuspid annulus, measuring 1.7×2.2 cm at its widest diameter. Cardiac MRI revealed a mass with dark intensity which enhanced heterogeneously following intravenous administration of gadolinium-chelate, consistent with a myxoma. The location of this myxoma, coupled with the presence of a stalk allowing mobility, provides a clue to how this patient experienced transient obstruction of the tricuspid valve leading to syncope. CONCLUSIONS: Right heart tumors should be considered in the differential diagnosis of unexplained syncope. Cardiac MRI with gadolinium-chelate administration can help differentiate this tumor from a right-sided atrial thrombus, which can pose a diagnostic challenge.

A Rare Association of Sinus Venosus-Type Atrial Septal Defect and Persistent Left Superior Vena Cava Detected by Transthoracic Echocardiography and Cardiac Magnetic Resonance Imaging.

BACKGROUND: Association of persistent left superior vena cava (PLSVC) and sinus venosus-type atrial septal defect (SVASD) is rare. We describe a patient with dilated coronary sinus (CS) found to have PLSVC and SVASD. CASE REPORT: The patient is a 60-year-old man with history of stroke who underwent a transthoracic echocardiogram (TTE) for evaluation of shortness of breath. TTE demonstrated a markedly dilated CS. Agitated saline was injected into the left antecubital vein to further assess CS. The parasternal long axis view demonstrated immediate filling of the CS and confirmed the presence of a PLSVC. Apical 4-chamber view with injection of agitated saline into the right antecubital vein demonstrated immediate contrast opacification of both atria, consistent with a right to left cardiac shunt. Cardiac magnetic resonance (CMR) was performed, which confirmed the TTE findings of PLSVC and defined the cardiac shunt as SVASD. CONCLUSIONS: PLSVC should be suspected in a patient with an abnormally dilated CS. In this case we identified a rare association of PLSVC with a SVASD. TTE with agitated saline contrast injection and CMR are useful diagnostic tools for PLSVC and associated cardiac congenital anomalies, respectively.

Correlates of myocardial oxygen demand measured by positron emission tomography in the hypertrophied left ventricle.

BACKGROUND: The aim of this study was to identify the best correlate of myocardial oxygen demand (MVO(2)) in patients with hypertension induced left ventricular hypertrophy (LVH), and to examine whether relationships between these surrogates and MVO(2) differed between patients with LVH and control subjects. METHODS: We measured MVO(2) by positron emission tomography using carbon-11 acetate in 20 patients and 10 normotensive control subjects, and compared the relationships between commonly used surrogates and MVO(2). RESULTS: With the exception of diastolic blood pressure, the same variables correlated with resting MVO(2) in the patients and control subjects. CONCLUSIONS: The best correlate of resting MVO(2) in the patients with hypertension induced LVH was the stress-mass-heart rate product.

Myocardial blood flow and efficiency in concentric and eccentric left ventricular hypertrophy.

BACKGROUND: It is not clearly understood why concentric left ventricular hypertrophy (increased left ventricular mass and relative wall thickness) is associated with higher cardiovascular risk than eccentric hypertrophy (increased left ventricular mass but normal relative wall thickness). Possible reasons include lower myocardial efficiency or perfusion reserve in concentric than in eccentric hypertrophy. We compared myocardial perfusion reserve and efficiency in normotensive controls and in hypertensive patients with concentric and with eccentric hypertrophy. METHODS: Study subjects comprised 16 patients with hypertension-induced left ventricular hypertrophy and 10 normotensive controls. We measured myocardial perfusion reserve and oxygen consumption by positron emission tomography. We calculated myocardial efficiency by dividing left ventricular minute work by myocardial oxygen consumption. RESULTS: There was no significant difference in myocardial perfusion reserve between patients with concentric (n = 9) as compared to eccentric (n = 7) hypertrophy. However, myocardial perfusion reserve in both patient groups were lower than in controls. Although myocardial efficiency in patients with eccentric hypertrophy and in controls were not different, both values were higher than measurements in patients with concentric hypertrophy (18% +/- 6% v 16% +/- 3% v 13% +/- 4%, eccentric hypertrophy versus controls versus concentric hypertrophy, respectively, P =.04 for both eccentric versus concentric hypertrophy and for controls versus concentric hypertrophy). CONCLUSIONS: Myocardial efficiency but not perfusion reserve is lower in hearts with concentric compared with eccentric left ventricular hypertrophy. This might be an explanation for the higher cardiovascular morbidity and mortality associated with concentric left ventricular hypertrophy.

Positron emission tomography, echo-doppler, and exercise studies of functional capacity in hypertensive heart disease.

BACKGROUND: This study examines the relationship between functional capacity, left ventricular diastolic function, and myocardial perfusion reserve (MPR) in patients with left ventricular hypertrophy (LVH). METHODS: We studied 16 patients with LVH and 10 controls. Functional capacity was assessed by cardiopulmonary exercise, MPR by positron emission tomography, and left ventricular diastolic function by echo-Doppler. RESULTS: Functional capacity and MPR were significantly lower in the patients. Functional capacity correlated positively with MPR and left ventricular diastolic function. CONCLUSIONS: Diminished functional capacity in patients with hypertension-induced LVH is related to the impairment in MPR and left ventricular diastolic function.

Myocardial first pass perfusion: steady-state free precession versus spoiled gradient echo and segmented echo planar imaging.

The imaging sequences used in first pass (FP) perfusion to date have important limitations in contrast-to-noise ratio (CNR), temporal and spatial resolution, and myocardial coverage. As a result, controversy exists about optimal imaging strategies for FP myocardial perfusion. Since imaging performance varies from subject to subject, it is difficult to form conclusions without direct comparison of different sequences in the same subject. The purpose of this study was to directly compare the saturation recovery SSFP technique to other more commonly used myocardial first pass perfusion techniques, namely spoiled GRE and segmented EPI. Differences in signal-to-noise ratio (SNR), CNR, relative maximal upslope (RMU) of signal amplitude, and artifacts at comparable temporal and spatial resolution among the three sequences were investigated in computer simulation, contrast agent doped phantoms, and 16 volunteers. The results demonstrate that SSFP perfusion images exhibit an improvement of approximately 77% in SNR and 23% in CNR over spoiled GRE and 85% SNR and 50% CNR over segmented EPI. Mean RMU was similar between SSFP and spoiled GRE, but there was a 58% increase in RMU with SSFP versus segmented EPI.