The Emerging Specialty of Cardio-Rheumatology.

PURPOSE OF REVIEW: In this review, we aimed to summarize the different aspects of the field of cardio-rheumatology, the role of the cardio-rheumatologist, and future research in the field. RECENT FINDINGS: Cardio-rheumatology is an emerging subspecialty within cardiology that focuses on addressing the intricate relationship between systemic inflammation and cardiovascular diseases. It involves understanding the cardiovascular impact of immune-mediated inflammatory diseases on the heart and vascular system. A cardio-rheumatologist's role is multifaceted. First, they should understand the cardiac manifestations of rheumatological diseases. They should also be knowledgeable about the different immunotherapies available and side effects. Additionally, they should know how to utilize imaging modalities, either for diagnosis, prognosis, or treatment monitoring. This field is constantly evolving with new research on both treatment and imaging of the effects of inflammation on the cardiovascular system.

Artificial intelligence in preventive cardiology.

Artificial intelligence (AI) is a field of study that strives to replicate aspects of human intelligence into machines. Preventive cardiology, a subspeciality of cardiovascular (CV) medicine, aims to target and mitigate known risk factors for CV disease (CVD). AI's integration into preventive cardiology may introduce novel treatment interventions and AI-centered clinician assistive tools to reduce the risk of CVD. AI's role in nutrition, weight loss, physical activity, sleep hygiene, blood pressure, dyslipidemia, smoking, alcohol, recreational drugs, and mental health has been investigated. AI has immense potential to be used for the screening, detection, and monitoring of the mentioned risk factors. However, the current literature must be supplemented with future clinical trials to evaluate the capabilities of AI interventions for preventive cardiology. This review discusses present examples, potentials, and limitations of AI's role for the primary and secondary prevention of CVD.

Epidemiology and Prognostic Implications of Coronary Artery Calcium in Asymptomatic Individuals With Prediabetes: A Multicohort Study.

OBJECTIVE: To describe the epidemiology and prognostic value of coronary artery calcium (CAC) in individuals with prediabetes. RESEARCH DESIGN AND METHODS: We pooled participants free of clinical atherosclerotic cardiovascular disease (ASCVD) from four prospective cohorts: the Multi-Ethnic Study of Atherosclerosis, Heinz Nixdorf Recall Study, Framingham Heart Study, and Jackson Heart Study. Two definitions were used for prediabetes: inclusive (fasting plasma glucose [FPG] ≥100 to <126 mg/dL and hemoglobin A1c [HbA1c] ≥5.7% to <6.5%, if available, and no glucose-lowering medications) and restrictive (FPG ≥110 to <126 mg/dL and HbA1c ≥5.7% to <6.5%, if available, among participants not taking glucose-lowering medications). RESULTS: The study included 13,376 participants (mean age 58 years; 54% women; 57% White; 27% Black). The proportions with CAC ≥100 were 17%, 22%, and 37% in those with euglycemia, prediabetes, and diabetes, respectively. Over a median (25th-75th percentile) follow-up time of 14.6 (interquartile range 7.8-16.4) years, individuals with prediabetes and CAC ≥100 had a higher unadjusted 10-year incidence of ASCVD (13.4%) than the overall group of those with diabetes (10.6%). In adjusted analyses, using the inclusive definition of prediabetes, compared with euglycemia, the hazard ratios (HRs) for ASCVD were 0.79 (95% CI 0.62, 1.01) for prediabetes and CAC 0, 0.70 (0.54, 0.89) for prediabetes and CAC 1-99, 1.54 (1.27, 1.88) for prediabetes and CAC ≥100, and 1.64 (1.39, 1.93) for diabetes. Using the restrictive definition, the HR for ASCVD was 1.63 (1.29, 2.06) for prediabetes and CAC ≥100. CONCLUSIONS: CAC ≥100 is frequent among individuals with prediabetes and identifies a high ASCVD risk subgroup in which the adjusted ASCVD risk is similar to that in individuals with diabetes.

Ejection fraction and ventricular volumes on rubidium positron emission tomography: Validation against cardiovascular magnetic resonance.

BACKGROUND: Cardiovascular magnetic resonance (CMR) is the non-invasive gold standard for non-invasively determining left ventricular volumes (LVVs) and ejection fraction (EF). We aimed to assess the accuracy of LVV and left ventricular ejection fraction measured by positron emission tomography (PET) as compared to CMR. METHODS: Patients who underwent both PET and CMR within 1 year were identified from prospective institutional registries. Analysis was performed to evaluate the agreement between the raw and body-surface-area-normalized left ventricular volume (LVV) and EF derived from PET vs. those derived from CMR. RESULTS: The study population consisted of 669 patients (mean age 62 ± 13 years, 65% male). The median (interquartile range [IQR]) duration between CMR and PET imaging was 36 (7-118) days. The median (IQR) EF values were 52% (38-63%) on CMR and 53% (37-65%) on PET (mean difference: 0.53% ± 9.1, P = 0.129) with a strong correlation (Spearman rho = 0.84, P < 0.001; Intraclass Correlation Coefficient 0.84, 95% confidence interval [CI]: 0.82-0.86, P < 0.001; Lin's concordance correlation coefficient was 0.844, 95% CI: 0.822 to 0.865). Results were similar with LVV, normalized LVV/EF, and in subgroups of patients with reduced EF, coronary artery disease scar, and LV hypertrophy as well as in patients with defibrillators. However, PET tended to underestimate LVV compared to CMR. CONCLUSION: Our analysis showed a strong correlation of EF and LVV by PET against a reference standard of CMR, whereas PET significantly underestimated LVV, but not EF, compared to CMR.

Unveiling the Hidden Patterns: Multimodality Cardiac Imaging in Takotsubo Cardiomyopathy Diagnosis.

Takotsubo cardiomyopathy, also known as stress cardiomyopathy, is a reversible form of cardiomyopathy characterized by reduced ejection fraction with regional wall motion abnormalities, elevated cardiac enzyme levels, and signs of ischemia on electrocardiogram despite the absence of obstructive epicardial coronary artery disease. It is often preceded by intense emotional or physical illness stressors. This case describes a 65-year-old female patient who likely developed takotsubo cardiomyopathy precipitated by the stress of diverticulitis.

Obesity management for cardiovascular disease prevention.

Background: Obesity is a complex disease that leads to higher morbidity and mortality and its rate in the United States is rapidly rising. Targeting obesity management is one of the cornerstones of preventive medicine. Early intervention can significantly reduce the risk of developing cardiovascular disease. While it is well known that lifestyle interventions such as healthful nutrition and routine physical activity are the first and most important step in management, some do not achieve the desired results and require further therapies. Methods: A literature review was conducted, that included clinical documents, public scientific citations and peer review articles to evaluate anti-obesity medications, endoscopic procedures and bariatric surgeries in the management of obesity. We also included effects of these interventions on weight loss, cardiovascular disease risk reduction and side effects. Results: This clinical review summarizes recent evidence for the different approaches in obesity management including medications, common endoscopic procedures and bariatric surgeries. For more detailed review on the different management options discussed, we recommend reviewing Obesity Medicine Association Clinical Practice Statement [1]. Conclusion: Management of obesity reduces cardiovascular risk, improves metabolic parameters and other important health outcomes. Different management approaches are available, hence, a high level of awareness of the growing epidemic of obesity is needed to ensure timely referrals to obesity medicine specialists.

Determining call-to-entry rate and recruitment barriers in clinical studies for community clinics serving low-income populations: a cohort study.

BACKGROUND: Recruitment for clinical studies is challenging. To overcome barriers, investigators have previously established call-to-entry rates to assist in planning. However, rates specific to low-income minority populations are needed to account for additional barriers to enrolment these individuals face. OBJECTIVE: To obtain a call-to-entry rate in a low-income uninsured Hispanic population with chronic disease. METHODS: We used data from four of our randomised clinical studies to determine the call-to-entry rate for individuals (n=1075) with or at risk for type 2 diabetes: participants needed/potential participants contacted=recruitment rate (yield). Research staff contacted potential participants to enrol in a study that evaluated 6 month diabetes programmes at community clinics from 2015 to 2020. We recorded call-to-entry rates, reasons for declining the study, show rates, and attrition. RESULTS: The call-to-entry rate was 14.5%. Forty per cent of potential participants could not be contacted, and 30.6%, 19.1%, and 5.4% responded yes, no, and maybe, respectively. No show percentages were 54% for yes and 91.4% for maybe responders. The majority (61.6%) declined due to inability to attend; reasons to decline included work (43%), eligibility (18%), transportation (10%), out of town (9%), did not think they needed the programme (7%) and other/unknown (14%). Being a physician predicted inability to reach participants (adjusted OR 2.91, 95% CI 1.73 to 4.90). Attrition was 6.8%. CONCLUSIONS: We described a call-to-entry rate and detailed recruitment data, including reasons to decline the study. This valuable information can assist investigators in study planning and overcoming enrolment barriers in low-income populations. Telehealth-based or strategies that limit transportation needs may increase participant involvement. TRIAL REGISTRATION NUMBER: NCT03394456.

Prognostic value of positron emission tomography derived myocardial flow reserve: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Positron Emission Tomography (PET)-derived myocardial flow reserve (MFR) has been shown to have a role in the diagnosis and prognosis of patients with coronary artery disease (CAD). We performed a systematic review and meta-analysis to summarize the body of literature and synthesize the evidence on the prognostic role of PET-derived MFR in patients with known or suspected CAD. METHODS: A comprehensive literature search of the Medline database from its inception to August 2023, in humans, in any language, was conducted for clinical studies examining the prognostic value of PET imaging in patients of any age, sex, and CAD status. Systematic screening and data extraction of the identified studies were followed by quantitative meta-analysis of PET-MFR's role in predicting adverse clinical events using random effect model. Studies were appraised using the modified Newcastle-Ottawa tool. RESULTS: A total of 21 studies assessing the prognostic role of PET derived MFR in 46,815 patients with known and/or suspected CAD were included (mean (SD) age 66 (4) years, 48% women). The mean follow-up duration was 36 months (range 10-96). Cardiovascular risk factors were prevalent (73% hypertension, 35% diabetes and 67% dyslipidemia). The definition of the composite outcome varied between studies, with various combinations of mortality, non-fatal myocardial infarction, hospitalization, and coronary revascularization. Pooled impaired MFR was significantly associated with an increased risk of adverse outcomes (RR = 2.94, 95% CI 2.42-3.56, p < 0.001). Results were similar in a subgroup of patients with suspected CAD. CONCLUSIONS: The available body of evidence shows that impaired PET-derived MFR measured using different tracers and PET systems is strongly associated with an increased risk of adverse cardiovascular events. Limitations of this review include observational nature of studies, marked heterogeneity in patient populations, inconsistency in thresholds to define abnormal MFR, and differing components for the composite outcome.

Age-Related Differences in the Contribution of Systolic Blood Pressure and Biomarkers to Cardiovascular Disease Risk Prediction: The Atherosclerosis Risk in Communities (ARIC) Study.

We sought to determine how biomarkers known to be associated with hypertension-induced end-organ injury complement the use of systolic blood pressure (SBP) for cardiovascular disease (CVD) risk prediction at different ages. Using data from visits 2 (1990 to 1992) and 5 (2011 to 2013) of the Atherosclerosis Risk in Communities (ARIC) study, 3 models were used to predict CVD (composite of coronary heart disease, stroke, and heart failure). Model A included traditional risk factors (TRFs) except SBP, model B-TRF plus SBP, and model C-TRF plus biomarkers (high-sensitivity troponin T [hsTnT] and N-terminal pro-B-type natriuretic peptide [NT-proBNP]). Harrel's C-statistics were used to assess risk discrimination for CVD comparing models B and A and C and B. At visit 2, the addition of SBP to TRF (model B vs model A) significantly improved the C-statistic (∆C-statistic, 95% confidence interval 0.010, 0.007 to 0.013) whereas the addition of hsTnT to TRF (model C vs model B) decreased the C-statistic (∆C-statistic -0.0038, -0.0075 to -0.0001) compared with SBP. At visit 5, the addition of SBP to TRF did not significantly improve the C-statistic (∆C-statistic 0.001, -0.002 to 0.005) whereas the addition of both hsTnT and NT-proBNP to TRF significantly improved the C-statistic compared with SBP (∆C-statistic 0.028, 0.015 to 0.041 and 0.055, 0.036 to 0.074, respectively). In summary, the incremental value of SBP for CVD risk prediction diminishes with age whereas the incremental value of hsTnT and NT-proBNP increases with age.

Prognostic value of global myocardial flow reserve in patients with history of coronary artery bypass grafting.

AIMS: It is not well understood whether positron emission tomography (PET)-derived myocardial flow reserve (MFR) is prognostic among patients with prior coronary artery bypass grafting (CABG). METHODS AND RESULTS: Consecutive patients with a clinical indication for PET were enrolled in the Houston Methodist DeBakey Heart and Vascular Center PET registry and followed prospectively for incident outcomes. The primary outcome was a composite of all-cause death, myocardial infarction (MI)/unplanned revascularization, and heart failure admissions. Cox proportional hazards models were used to study the association between MFR (<2 vs. ≥2) and incident events adjusting for clinical and myocardial perfusion imaging variables. The study population consisted of 836 patients with prior CABG; mean (SD) age 68 (10) years, 53% females, 79% Caucasian, 36% non-Hispanic, and 66% with MFR <2. Over a median (interquartile range [IQR]) follow-up time of 12 (4-24) months, there were 122 incident events (46 HF admissions, 28 all-cause deaths, 23 MI, 22 PCI/3 repeat CABG 90 days after imaging). In adjusted analyses, patients with impaired MFR had a higher risk of the primary outcome [hazard ratio (HR) 2.06; 95% CI 1.23-3.44]. Results were significant for admission for heart failure admissions (HR 2.92; 95% CI 1.11-7.67) but not for all-cause death (HR 2.01, 95% CI 0.85-4.79), or MI/UR (HR 1.93, 95% CI 0.92-4.05). CONCLUSION: Among patients with a history of CABG, PET-derived global MFR <2 may identify those with a high risk of subsequent cardiovascular events, especially heart failure, independent of cardiovascular risk factors and perfusion data.

Association of interleukin-6 and interleukin-18 with cardiovascular disease in older adults: Atherosclerosis Risk in Communities study.

AIMS: Interleukin-6 (IL-6) and interleukin-18 (IL-18), important cytokines implicated in atherosclerosis and inflammaging, were assessed for associations with global cardiovascular disease (CVD), atrial fibrillation (AF), and death in older adults. METHODS AND RESULTS: Participants from Atherosclerosis Risk in Communities study Visit 5 (mean age 75.4 ± 5.1 years) with IL-6 and IL-18 measurements were included (n = 5672). Cox regression models were used to assess associations of IL-6 and IL-18 with coronary heart disease (CHD), ischaemic stroke, heart failure (HF) hospitalization, global CVD (composite of CHD, stroke, and HF), AF, and all-cause death. Over a median follow-up of 7.2 years, there were 1235 global CVD events, 530 AF events, and 1173 deaths. Higher IL-6 [hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.44-1.72 per log unit increase] and IL-18 (HR 1.13, 95% CI 1.01-1.26) were significantly associated with global CVD after adjustment for cardiovascular risk factors. Association between IL-6 and global CVD remained significant after further adjustment for high-sensitivity C-reactive protein (hs-CRP), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and high-sensitivity troponin T (hs-TnT) but was no longer significant for IL-18 after further adjustments. Interleukin-6 was also associated with increased risk for CHD, HF, and AF after adjustment for covariates. Both IL-6 and IL-18 were associated with increased risk for all-cause death independent of cardiovascular risk factors and other biomarkers. CONCLUSION: Among older adults, both IL-6 and IL-18 were associated with global CVD and death. The association between IL-6 with CVD appears to be more robust and was independent of hs-CRP, NT-proBNP, and hs-TnT.

In older adults in the Atherosclerosis Risk in Communities study (average age 75 years), higher levels of interleukin-6 and interleukin-18, two proteins implicated in atherosclerosis and increased inflammation that occurs with ageing, significantly increased risk for global cardiovascular disease (including coronary heart disease, stroke, and heart failure) during the next ∼7 years; interleukin-6 also increased risk for global cardiovascular disease, coronary heart disease, heart failure, and atrial fibrillation even after adjustment for other biomarkers of inflammation and subclinical myocardial injury, and both interleukin-6 and interleukin-18 were associated with increased risk for all-cause death independent of cardiovascular risk factors and other biomarkers. In older adults, higher levels of interleukin-6 and interleukin-18 were both associated with increased risk for global cardiovascular disease (including coronary heart disease, stroke, and heart failure) and death.The association between interleukin-6 and global cardiovascular disease appeared to be stronger than that for interleukin-18 and remained significant after adjustment for other biomarkers of inflammation and subclinical myocardial injury.

Coronary microvascular health in symptomatic patients with prior COVID-19 infection: an updated analysis.

AIMS: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with endothelial dysfunction. We aimed to determine the effects of prior coronavirus disease 2019 (COVID-19) on the coronary microvasculature accounting for time from COVID-19, disease severity, SARS-CoV-2 variants, and in subgroups of patients with diabetes and those with no known coronary artery disease. METHODS AND RESULTS: Cases consisted of patients with previous COVID-19 who had clinically indicated positron emission tomography (PET) imaging and were matched 1:3 on clinical and cardiovascular risk factors to controls having no prior infection. Myocardial flow reserve (MFR) was calculated as the ratio of stress to rest myocardial blood flow (MBF) in mL/min/g of the left ventricle. Comparisons between cases and controls were made for the odds and prevalence of impaired MFR (MFR < 2). We included 271 cases matched to 815 controls (mean ± SD age 65 ± 12 years, 52% men). The median (inter-quartile range) number of days between COVID-19 infection and PET imaging was 174 (58-338) days. Patients with prior COVID-19 had a statistically significant higher odds of MFR <2 (adjusted odds ratio 3.1, 95% confidence interval 2.8-4.25 P < 0.001). Results were similar in clinically meaningful subgroups. The proportion of cases with MFR <2 peaked 6-9 months from imaging with a statistically non-significant downtrend afterwards and was comparable across SARS-CoV-2 variants but increased with increasing severity of infection. CONCLUSION: The prevalence of impaired MFR is similar by duration of time from infection up to 1 year and SARS-CoV-2 variants, but significantly differs by severity of infection.

Factors Associated With Sex Disparities in Leisure-Time Physical Activity: An Analysis of the Behavioral Risk Factor Surveillance System, 2011 to 2021.

OBJECTIVE: To identify whether sex disparities in leisure-time physical activity (LTPA) vary across population subgroups. PARTICIPANTS AND METHODS: We used data from the Behavioral Risk Factor Surveillance System (BRFSS) spanning 2011 to 2021. We examined subgroups by age, race/ethnicity, income, employment, education, marital status, body mass index, and cardiometabolic comorbidities (diabetes, hypertension, and cardiovascular disease) to identify where sex disparities in LTPA are most pronounced. RESULTS: Among 4,415,992 respondents (57.4% [2,533,234] women and 42.6% [1,882,758] men), women were less likely than men to report LTPA (73.0% vs 76.8%; odds ratio [OR], 0.817; 95% CI, 0.809 to 0.825). The gap was widest between the youngest (OR for the 18- to 24-year age group, 0.71; 95% CI, 0.68 to 0.74) and oldest (OR for the 80 years or older age group, 0.71; 95% CI, 0.69 to 0.73) respondents but was narrower between middle-aged adults (OR for the 50- to 59-year age group, 0.95; 95% CI, 0.93 to 0.97). Disparity was greater among non-Hispanic Black participants (OR, 0.70; 95% CI, 0.68 to 0.72) and Hispanic participants (OR, 0.79; 95% CI, 0.77 to 0.81) than among non-Hispanic White participants (OR, 0.85; 95% CI, 0.84 to 0.86). Disparities were greater at the lowest income levels (OR, 0.81; 95% CI, 0.78 to 0.85) and lower at the highest income levels (OR, 0.94; 95% CI, 0.91 to 0.96). The disparity was greater in unemployed individuals (OR, 0.78; 95% CI, 0.76 to 0.80) compared with employed individuals (OR, 0.91; 95% CI, 0.90 to 0.92). Moreover, disparity was greater in individuals with a body mass index in the overweight or obese range and those with diabetes, hypertension, or cardiovascular disease. CONCLUSION: Women are less likely than men to engage in LTPA. These disparities are greatest among the young and elderly, Black and Hispanic individuals, lower income and unemployed individuals, and individuals with cardiometabolic disease. Targeted interventions are needed to reduce sex-related disparities.

Reclassification of Pre-Heart Failure Stages Using Cardiac Biomarkers: The ARIC Study.

BACKGROUND: The recent heart failure (HF) guideline recommends the inclusion of cardiac biomarkers in defining Stage B HF. OBJECTIVES: The authors evaluated the impact of incorporating cardiac biomarkers to reclassify HF in 5,324 participants (mean age: 75.8 years) without prevalent HF enrolled in the ARIC (Atherosclerosis Risk In Communities) study and assessed prognosis of Stage B using cardiac biomarkers. METHODS: Using N-terminal pro-B-type natriuretic peptide (<125 pg/mL or ≥125 pg/mL), high-sensitivity troponin T (<14 ng/L or ≥14 ng/L), and abnormal cardiac structure/function by echocardiography, individuals were classified as Stage Anew and Stage Bnew HF, respectively. Stage Bnew was further evaluated as elevated biomarker only, abnormal echocardiogram only, and abnormalities in both (echo + biomarker). The authors assessed risk for incident HF and all-cause death using Cox regression. RESULTS: Overall, 4,326 (81.3%) individuals were classified as Stage Bnew with 1,123 (21.1%) meeting criteria for elevated biomarkers only. Compared with Stage Anew, Stage Bnew was associated with increased risk for incident HF (HR: 3.70 [95% CI: 2.58-5.30]) and death (HR: 1.94 [95% CI: 1.53-2.46]). Stage Bbiomarkers only and Stage Becho only were associated with increased HF risk, whereas Stage Bbiomarkers only was also associated with increased death. Stage Becho+biomarker had the highest risk for HF (HR: 6.34 [95% CI: 4.37-9.19]) and death (HR: 2.53 [95% CI: 1.98-3.23]). CONCLUSIONS: Incorporating biomarkers based on the new HF guideline reclassified approximately 1 in 5 older adults without prevalent HF to Stage B. The routine measurement of biomarkers can help to identify individuals at higher HF risk who may benefit most from HF prevention efforts.