Carotid Intima-Media Thickness and Improved Stroke Risk Assessment in Hypertensive Black Adults.

BACKGROUND: We aim to determine the added value of carotid intima-media thickness (cIMT) in stroke risk assessment for hypertensive Black adults. METHODS: We examined 1,647 participants with hypertension without a history of cardiovascular (CV) disease, from the Jackson Heart Study. Cox regression analysis estimated hazard ratios (HRs) for incident stroke per standard deviation increase in cIMT and quartiles while adjusting for baseline variables. We then evaluated the predictive capacity of cIMT when added to the pool cohort equations (PCEs). RESULTS: The mean age at baseline was 57 ± 10 years. Each standard deviation increase in cIMT (0.17 mm) was associated with approximately 30% higher risk of stroke (HR 1.27, 95% confidence interval: 1.08-1.49). Notably, cIMT proved valuable in identifying residual stroke risk among participants with well-controlled blood pressure, showing up to a 56% increase in the odds of stroke for each 0.17 mm increase in cIMT among those with systolic blood pressure <120 mm Hg. Additionally, the addition of cIMT to the PCE resulted in the reclassification of 58% of low to borderline risk participants with stroke to a higher-risk category and 28% without stroke to a lower-risk category, leading to a significant net reclassification improvement of 0.22 (0.10-0.30). CONCLUSIONS: In this community-based cohort of middle-aged Black adults with hypertension and no history of CV disease at baseline, cIMT is significantly associated with incident stroke and enhances stroke risk stratification.

Effects of atherectomy on major adverse limb events for femoropopliteal interventions: Vascular Quality Initiative registry.

BACKGROUND: Atherectomy use in treatment of femoropopliteal disease has significantly increased despite scant evidence of benefit to long-term clinical outcomes. AIMS: We investigated the clinical benefits of atherectomy over standard treatment for femoropopliteal interventions. METHODS: Using data from the Society of Vascular Surgery's Vascular Quality Initiative (VQI) registry, we identified patients who underwent isolated femoropopliteal interventions for occlusive disease. We compared 13,423 patients treated with atherectomy with 47,371 receiving standard treatment; both groups were allowed definitive treatment with a drug-coated balloon or stenting. The primary endpoint was major adverse limb events (MALEs), which is a composite of target vessel re-occlusion, ipsilateral major amputation, and target vessel revascularization. RESULTS: Mean age was 69 ± 11 years, and patients were followed for a median of 30 months. Overall rates of complications were slightly higher in the atherectomy group than the standard treatment group (6.2% vs. 5.9%, p < 0.0001). In multivariable analysis, after adjusting for demographic and clinical covariates, atherectomy use was associated with a 13% reduction in risk of MALEs (adjusted odds ratio [aOR]: 0.87; 95% confidence interval [CI]: 0.77-0.98). Rates of major and minor amputations were significantly lower in the atherectomy group (3.2% vs. 4.6% and 3.3% vs. 4.3%, respectively, both p < 0.001), primarily driven by a significantly decreased risk of major amputations (aOR 0.69; 95% CI: 0.52-0.91). There were no differences in 30-day mortality, primary patency, and target vessel revascularization between the atherectomy and standard treatment groups. CONCLUSIONS: In adults undergoing femoropopliteal interventions, the use of atherectomy was associated with a reduction in MALEs compared with standard treatment.

Impact of a Resident-Driven Research Club on Scholarly Activity in an Academic Internal Medicine Residency Program During the COVID-19 Pandemic.

OBJECTIVES: Traditional journal clubs have been shown to be insufficient in improving residents' scholarly productivity, often due to the inability to sustain residents' interest and participation. Additionally, the 2019 novel coronavirus (COVID-19) pandemic restrictions caused a decline in academic scholarly productivity across residency programs. We evaluated the impact of a resident-led research club called 'journal café' on residents' scholarly productivity by comparing scholarly output between the journal café members and non-members during the COVID-19 pandemic. METHODS: The journal café was established in the 2012/2013 academic year by internal medicine residents of a university residency program in Atlanta, Georgia, to foster self-directed collaboration among residents based on shared interests in academic research. The journal café runs independently of the residency program's journal club. We categorized IM residents at our institution into journal café members and non-members and collected data on their research productivity during residency training and the COVID-19 pandemic. The survey was conducted between April and June 2021 and analyzed data presented using frequencies, tables, and appropriate charts. RESULTS: Sixty-eight residents (29 journal café members and 39 non-members) completed the survey (response rate of 85%). A significantly higher number of journal café members reported having five or more research publications (55.1% vs 7.1%, P < .001) and scientific presentations (48.3% vs 2.6%, P < .001) compared with non-members. Additionally, more journal café members published COVID-19-related research in peer-reviewed journals compared with non-members (68% vs 32%, n = 19). Finally, most of the residents cited the opportunity of a platform to share and brainstorm on research ideas as the reason for joining the journal café. CONCLUSION: We found an association between journal café participation and increased scholarly activity, particularly during the COVID-19 pandemic. Independent resident-led research clubs supported by the residency program may complement the traditional journal clubs and enhance residents' participation in research.

Adiposity, aldosterone and plasma renin activity among African Americans: The Jackson Heart Study.

Objective: To analyze associations between adiposity and the renin-angiotensin-aldosterone system (RAAS) in a large African American (AA) cohort. Methods: Cross-sectional associations of adiposity (body mass index [BMI], waist circumference [WC], waist:height ratio, waist:hip ratio, leptin, adiponectin, leptin:adiponectin ratio [LAR], subcutaneous [SAT] and visceral adipose tissue [VAT], and liver attenuation [LA]) with aldosterone, plasma renin activity (renin), and aldosterone:renin ratio (ARR) were assessed in the Jackson Heart Study using adjusted linear regression models. Results: A 1-SD higher BMI was associated with a 4.8 % higher aldosterone, 9.4 % higher renin, and 5.0 % lower ARR (all p < 0.05). Log-leptin had the largest magnitude of association with renin (30.2 % higher) and ARR (9.6 % lower), while the strongest association of aldosterone existed for log-LAR (15.3 % higher) (all 1-SD, p < 0.05). SAT was only associated with renin. VAT was associated with higher aldosterone, renin, and ARR. Liver fat was associated with aldosterone and renin, but not ARR. Associations of WC, BMI, and SAT with aldosterone were greater in men while the association with VAT was greater in women (p-interactions < 0.05). Conclusion: Multiple measures of adiposity are associated with the RAAS in AAs. Further studies should examine the role of RAAS in obesity-driven cardiometabolic diseases.

Comparison of Percutaneous Coronary Intervention-Related Adverse Cardiac Outcomes in Patients With in-stent vs de novo Chronic Total Occlusion: A Systematic Review and Meta-Analysis.

Contemporary literature reveals a range of cardiac complications in patients who receive the percutaneous coronary intervention (PCI) for chronic total occlusion (CTO). This study compared the adverse cardiac outcomes and procedural/technical success rates between the patients groups of in-stent (IS) CTO PCI and de novo CTO PCI. This systematic review and meta-analysis compared odds for primary (all-cause mortality, MACE, cardiac death post PCI, stroke) and secondary (bleeding requiring blood transfusion, ischemia-driven target-vessel revascularization, PCI procedural success, PCI technical success, and target-vessel MI) endpoints between 2734 patients who received PCI for IS CTO and 17,808 for de novo CTO. Odds ratios for outcome variables were calculated within 95% confidence intervals (CIs) via the Mantel-Haenszel method. The pooled analysis was undertaken for observational (retrospective/prospective) single- and multicentered studies published between January 2005 and December 2021. We found 57% higher, 166% higher, 129% higher, and 57% lower odds for MACE (OR: 1.57, 95% CI 1.31, 1.89, P < 0.001), ischemia-driven target-vessel revascularization (OR: 2.66, 95% CI 2.01, 3.53, P < 0.001), target-vessel myocardial infarction (MI) (OR: 2.29, 95% CI 1.70, 3.10, P < 0.001), and bleeding requiring blood transfusion (OR: 0.43, 95% CI 0.19, 1.00, P = 0.05), respectively, in patients with IS CTO PCI as compared to that of the de novo CTO PCI. No statistically significant differences between the study groups were recorded for the other primary/secondary outcome variables. The findings from this study indicated a high predisposition for MACE, ischemia-driven target-vessel revascularization, target vessel MI, and a lower incidence of bleeding episodes among IS CTO PCI patients as compared to those with de novo CTO PCI. The prognostic outcomes in CTO PCI cases require further investigation with randomized controlled trials.

The role of aldosterone and ideal cardiovascular health in incident cardiovascular disease: The Jackson heart study.

Background: Higher levels of ideal cardiovascular health (ICH) are associated with lower levels of aldosterone and incidence of cardiovascular disease (CVD). However, the degree to which aldosterone mediates the association between ICH and CVD incidence has not been explored. Thus, we investigated the mediational role of aldosterone in the association of 5 components of ICH (cholesterol, body mass index (BMI), physical activity, diet and smoking) with incident CVD and the mediational role of blood pressure (BP) and glucose in the association of aldosterone with incident CVD in a cohort of African Americans (AA). Methods: The Jackson Heart Study is a prospective cohort of AAs adults with data on CVD outcomes. Aldosterone, ICH metrics and baseline characteristics were collected at exam 1 (2000-2004). ICH score was developed by summing 5 ICH metrics (smoking, dietary intake, physical activity, BMI, and total cholesterol) and grouped into two categories (0-2 and ≥3 metrics). Incident CVD was defined as stroke, coronary heart disease, or heart failure. Cox proportional hazard regression models were used to model the association of categorical ICH score with incident CVD. The R Package Mediation was utilized to examine: 1) The mediational role of aldosterone in the association of ICH with incident CVD and 2) The mediational role of blood pressure and glucose in the association of aldosterone with incident CVD. Results: Among 3,274 individuals (mean age: 54±12.4 years, 65% female), there were 368 cases of incident CVD over a median of 12.7 years. The risk of incident CVD was 46% lower (HR: 0.54; 95%CI 0.36, 0.80) in those with ≥3 ICH metrics at baseline compared to 0-2. Aldosterone mediated 5.4% (p = 0.006) of the effect of ICH on incident CVD. A 1-unit increase in log-aldosterone was associated with a 38% higher risk of incident CVD (HR 1.38, 95%CI: 1.19, 1.61) with BP and glucose mediating 25.6% (p<0.001) and 4.8% (p = 0.048), respectively. Conclusion: Aldosterone partially mediates the association of ICH with incident CVD and both blood pressure and glucose partially mediate the association of aldosterone with incident CVD, emphasizing the potential importance of aldosterone and ICH in risk of CVD among AAs.

Updated Trends in Inferior Vena Cava Filter Use by Indication in the United States After Food and Drug Administration Safety Warnings: A Decade Analysis From 2010 to 2019.

BACKGROUND: Overall inferior vena cava filter (IVCF) utilization has decreased in the United States since the 2010 US Food and Drug Administration (FDA) safety communication. The FDA renewed this safety warning in 2014 with additional mandates on reporting IVCF-related adverse events. We evaluated the impact of the FDA recommendations on IVCF placements for different indications from 2010 to 2019 and further assessed utilization trends by region and hospital teaching status. METHODS: Inferior vena cava filter placements between 2010 and 2019 were identified in the Nationwide Inpatient Sample database using the associated International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision codes. Inferior vena cava filter placements were categorized by indication for venous thromboembolism (VTE) "treatment" in patients with VTE diagnosis and contraindication to anticoagulation and "prophylaxis" in patients without VTE. Generalized linear regression was used to analyze utilization trends. RESULTS: A total of 823 717 IVCFs were placed over the study period, of which 644 663 (78.3%) were for VTE treatment and 179 054 (21.7%) were for prophylaxis indications. The median age for both categories of patients was 68 years. The total number of IVCFs placed for all indications decreased from 129 616 in 2010 to 58 465 in 2019, with an aggregate decline rate of -8.4%. The decline rate was higher between 2014 and 2019 than between 2010 and 2014 (-11.6% vs -7.2%). From 2010 to 2019, IVCF placement for VTE treatment and prophylaxis trended downward at rates of -7.9% and -10.2%, respectively. Urban nonteaching hospitals saw the highest decline for both VTE treatment (-17.2%) and prophylactic indications (-18.0%). Hospitals located in the Northeast region had the highest decline rates for VTE treatment (-10.3%) and prophylactic indications (-12.5%). CONCLUSION: The higher decline rate in IVCF placements between 2014 and 2019 compared with 2010 and 2014 suggests an additional impact of the renewed 2014 FDA safety indications on national IVCF utilization. Variations in IVCF use for VTE treatment and prophylactic indications existed across hospital teaching types, locations, and regions. CLINICAL IMPACT: Inferior vena cava filters (IVCF) are associated with medical complications. The 2010 and 2014 FDA safety warnings appeared to have synergistically contributed to a significant decline in IVCF utilization rates from 2010 - 2019 in the US. IVC filter placements in patients without venous thromboembolism (VTE) declined at a higher rate than VTE. However, IVCF utilization varied across hospitals and geographical locations, likely due to the absence of universally accepted clinical guidelines on IVCF indications and use. Harmonization of IVCF placement guidelines is needed to standardize clinical practice, thereby reducing the observed regional and hospital variations and potential IVC filter overutilization.

Interpretation of A1C measurement in sub-Saharan Africa beyond the global A1C-Derived Average Glucose (ADAG) equation.

Introduction: optimal metabolic control is crucial for prevention of diabetes associated complications. HbA1c is a correlate of chronic hyperglycemia and is associated with long-term diabetes complications. We investigate the relationship between A1C and estimated average blood glucose (eAG) from the multicenter A1C-Derived Average Glucose (ADAG) study, in a sub-Saharan African population. Methods: forty-seven patients with diabetes mellitus and ten normoglycemic individuals were consecutively recruited from a tertiary reference hospital in Cameroon. This observational study was conducted in the framework of the ADAG study. eAG was derived from single values obtained from self-monitored blood glucose (SMBG) and from continuous glucose monitoring (CGM). Spearman correlation coefficient was used to examine the relationship between eAG and A1C levels. Results: there was a strong linear relationship between eAG using SMBG with A1C level; eAG (mmol/l) =1.22 x A1C (%) - 0.25; R2 = 0.58; p<0.001. This suggests that a one percent increase in A1C corresponds to a 1.22 mmol/l increment of eAG. A similar relationship was found between A1C level and eAG from the continuous glucose monitoring (CGM) measurements albeit with a smaller accretion; eAG (mmol/l) =0.95 x A1C (%) + 1.52; R2 = 0.52; p<0.001. The bias of the global ADAG equation was lower than 5% below A1C level of 7% and progressively increased with higher values of A1C. Conclusion: consistent with previous reports, using a population specific equation, A1C can be better derived from eAG in individuals from sub-Saharan African origin.

The role of aldosterone and ideal cardiovascular health in incident diabetes: The Jackson Heart Study.

Background: Greater attainment of ideal cardiovascular health (ICH) and lower serum aldosterone are associated with lower diabetes risk. Higher levels of ICH are associated with lower aldosterone. The mediational role of aldosterone in the association of ICH with incident diabetes remains unexplored. Thus, we examined the mediational role of aldosterone in the association of 5 ICH components (smoking, diet, physical activity, body mass index [BMI], and cholesterol) with incident diabetes. Additionally, we investigated the mediational role of glucose and blood pressure (BP) in the association of aldosterone with incident diabetes in an African American (AA) cohort. Methods: We conducted a prospective cohort analysis among AA adults, aged 21-94 years, in the Jackson Heart Study. Data on ICH, aldosterone, and cardiometabolic risk factors were collected at exam 1 (2000-2004). Diabetes (fasting glucose ≥ 126 mg/dL, physician diagnosis, use of diabetes drugs, or glycated hemoglobin ≥ 6.5%) was assessed at exams 1 through 3 (2009-2012). ICH metrics were defined by American Heart Association 2020 goals for smoking, dietary intake, physical activity, BMI, total cholesterol, BP and glucose. The number of ICH metrics attained at exam 1, excluding BP and fasting glucose, were summed (0-2, vs. 3+). R Package Mediation was used to examine: 1) The mediational role of aldosterone in the association of ICH with incident diabetes; and 2) the mediational role of BP and glucose in the association of aldosterone with incident diabetes. Results: Among 2,791 participants (mean age: 53±12, 65% female) over a median of 7.5 years, there were 497 incident diabetes cases. Risk of incident diabetes was 37% (HR: 0.63, 95%CI: 0.47, 0.84) lower in 3+ ICH category compared to 0-2 ICH category. Aldosterone mediated 6.98% (95% CI: 1.8%, 18.0%) of the direct effect of ICH on incident diabetes. A 1-unit increase in log-aldosterone was associated with a 44% higher risk of diabetes (HR 1.44, 95%CI 1.25-1.64). BP and glucose mediated 16.3% (95% CI: 7.0%, 31.0%) and 19.7% (95% CI: 6.5%, 34.0%) of the association of aldosterone with incident diabetes, respectively. Conclusion: Aldosterone is a mediator of the association of ICH with incident diabetes, whereas BP and glucose are mediators of the association of aldosterone with incident diabetes, emphasizing the importance of the renin-angiotensin-aldosterone system and ICH in lowering risk of diabetes in AA populations.

Trends and Outcomes of ST-Segment-Elevation Myocardial Infarction Among Young Women in the United States.

Background Although there has been a decrease in the incidence of ST-segment-elevation myocardial infarction (STEMI) in the United States, this trend might be stagnant or increasing in young women. We assessed the trends, characteristics, and outcomes of STEMI in women aged 18 to 55 years. Methods and Results We identified 177 602 women aged 18 to 55 with the primary diagnosis of STEMI from the National Inpatient Sample during years 2008 to 2019. We performed trend analyses to assess hospitalization rates, cardiovascular disease (CVD) risk factor profile, and in-hospital outcomes stratified by three age subgroups (18-34, 35-44, and 45-55 years). We found STEMI hospitalization rates were decreased in the overall study cohort from 52 per 100 000 hospitalizations in 2008 to 36 per 100 000 in 2019. This was driven by decreased proportion of hospitalizations in women aged 45 to 55 years (74.2% to-71.7%; P<0.001). Proportion of STEMI hospitalizationincreased in women aged 18-34 (4.7%-5.5%; P<0.001) and 35-44 years (21.2%-22.7%; P<0.001). The prevalence of traditional and non-traditional female-specific or female-predominant CVD risk factors increased in all age subgroups. The adjusted odds of in-hospital mortality in the overall study cohort and age subgroups were unchanged throughout the study period. Additionally, we observed an increase in the adjusted odds of cardiogenic shock, acute stroke, and acute kidney injury in the overall cohort over the study period. Conclusions STEMI hospitalizations are increasing among women aged <45 years, and in-hospital mortality has not changed over the past 12 years in women aged <55 years. Future studies on the optimization of risk assessment and management of STEMI in young women are urgently needed.

Impact of Hospital Safety-Net Burden on Outcomes of In-Hospital Cardiac Arrest in the United States.

High safety-net burden hospitals (HBHs) treating large numbers of uninsured or Medicaid-insured patients have generally been linked to worse clinical outcomes. However, limited data exist on the impact of the hospitals' safety-net burden on in-hospital cardiac arrest (IHCA) outcomes in the United States. OBJECTIVES: To compare the differences in survival to discharge, routine discharge home, and healthcare resource utilization between patients at HBH with those treated at low safety-net burden hospital (LBH). DESIGN SETTING AND PARTICIPANTS: Retrospective cohort study across hospitals in the United States: Hospitalized patients greater than or equal to 18 years that underwent cardiopulmonary resuscitation (CPR) between 2008 and 2018 identified from the Nationwide Inpatient Database. Data analysis was conducted in January 2022. EXPOSURE: IHCA. MAIN OUTCOMES AND MEASURES: The primary outcome is survival to hospital discharge. Other outcomes are routine discharge home among survivors, length of hospital stay, and total hospitalization cost. RESULTS: From 2008 to 2018, an estimated 555,016 patients were hospitalized with IHCA, of which 19.2% occurred at LBH and 55.2% at HBH. Compared with LBH, patients at HBH were younger (62 ± 20 yr vs 67 ± 17 yr) and predominantly in the lowest median household income (< 25th percentile). In multivariate analysis, HBH was associated with lower chances of survival to hospital discharge (adjusted odds ratio [aOR], 0.88; 95% CI, 0.85-0.96) and lower odds of routine discharge (aOR, 0.6; 95% CI, 0.47-0.75), compared with LBH. In addition, IHCA patients at publicly owned hospitals and those with medium and large hospital bed size were less likely to survive to hospital discharge, while patients with median household income greater than 25th percentile had better odds of hospital survival. CONCLUSIONS AND RELEVANCE: Our study suggests that patients who experience IHCA at HBH may have lower rates and odds of in-hospital survival and are less likely to be routinely discharged home after CPR. Median household income and hospital-level characteristics appear to contribute to survival.

Utilization trends and outcomes of catheter-directed thrombolysis for pulmonary embolism in the US by race/ethnicity.

Contemporary data on catheter-directed thrombolysis (CDT) utilization trends and associated hospital outcomes in pulmonary embolism (PE) n the US is limited. Using the nationwide inpatient sample database, we identified patients hospitalized for acute PE treated with CDT from January 1, 2008, to December 31, 2018. Cochrane-Armitage test was used to evaluate the temporal trends in utilization, hospital mortality, and major bleeding rates. Multivariate logistic regression was used to compare differences in the outcomes across race/ethnicity, 4444 patients (unweighted hospitalizations) underwent CDT during the study period. The mean age ± standard deviation of the population was 58 ± 16 years and the majority were males (54%). 3269 (73.6%) patients were non-Hispanic White (NHW), 802 (18.0%) patients were non-Hispanic Black (NHB), and 373 (8.4%) patients were of 'other' races/ethnicities. There was a more than tenfold increase in CDT use in 2018 compared to 2008. The total mortality and bleeding rates were approximately 7 and 10% respectively. Hospital mortality rates trended down across all races/ethnicities during the study period. A similar downward trend in bleeding rates was noted in NHB only (28.6% vs 10.7%, p = 0.04). In-hospital mortality and major bleeding odds were comparable across all races/ethnicities were comparable. NHB patients and other races were more likely to require blood transfusion and incur higher hospitalization costs compared with NHW patients. CDT use increased significantly in the US during the study period with a corresponding downward trend in in-hospital mortality across all races, and bleeding rates in NHB.

Associations of Cardiometabolic Multimorbidity With All-Cause and Coronary Heart Disease Mortality Among Black Adults in the Jackson Heart Study.

Importance: A combination of diabetes, coronary heart disease (CHD), and stroke has multiplicative all-cause mortality risk compared with any individual morbidity in White populations, but there is a lack of studies in Black populations in the US. Objective: To examine the association of cardiometabolic multimorbidity (diabetes, stroke, and CHD) individually and collectively with all-cause and CHD mortality. Design, Setting, and Participants: This cohort study included Black adults in the Jackson Heart Study followed over a median of 15 years. Baseline examinations were performed between 2000 and 2004, with follow-up on all-cause and CHD mortality through May 31, 2018. Participants were categorized into mutually exclusive groups at baseline: (1) free of cardiometabolic morbidity, (2) diabetes, (3) CHD, (4) stroke, (5) diabetes and stroke, (6) CHD and stroke, (7) diabetes and CHD, and (8) diabetes, stroke, and CHD. Data were analyzed from 2019 to 2021. Exposure: Cardiometabolic disease alone or in combination. Main Outcomes and Measures: The main outcomes were all-cause mortality and CHD mortality. Cox models estimated hazard ratios (HRs) with 95% CIs adjusted for sociodemographic and cardiovascular risk factors. Results: Among 5064 participants (mean [SD] age, 55.4 [12.8] years; 3200 [63%] women) in the Jackson Heart Study, 897 (18%) had diabetes, 192 (4%) had CHD, and 104 (2%) had a history of stroke. Among participants with cardiometabolic morbidities, the crude all-cause mortality rates were lowest for diabetes alone (24.4 deaths per 1000 person-years) and highest for diabetes, CHD, and stroke combined (84.1 deaths per 1000 person-years). For people with only 1 cardiometabolic morbidity, risk for all-cause mortality was highest for people with stroke (HR, 1.74; 95% CI, 1.24-2.42), followed by CHD (HR, 1.59 (95% CI, 1.22-2.08) and diabetes (HR, 1.50; 95% CI, 1.22-1.85), compared with no cardiometabolic morbidities. There were also increased risks of mortality with combinations of diabetes and stroke (HR, 1.71; 95% CI, 1.09-2.68), CHD and stroke (HR, 2.23; 95% CI, 1.35-3.69), and diabetes and CHD (HR, 2.28; 95% CI, 1.65-3.15). The combination of diabetes, stroke, and CHD was associated with the highest all-cause mortality (HR, 3.68; 95% CI, 1.96-6.93). Findings were similar for CHD mortality, but with a larger magnitude of association (eg, diabetes, stroke, and CHD: HR, 13.52; 95% CI, 3.38-54.12). Conclusions and Relevance: In this cohort study, an increasing number of cardiometabolic multimorbidities was associated with a multiplicative increase in risk of all-cause mortality among Black adults, with a greater magnitude of association for CHD mortality.

Vitamin D, parathyroid hormone, glucose metabolism and incident diabetes in the multiethnic study of atherosclerosis.

INTRODUCTION: Higher concentrations of serum 25-hydroxyvitamin D (25(OH)D) and lower concentrations of parathyroid hormone (PTH) are associated with lower insulin resistance and incident diabetes in non-Hispanic White and Hispanic Americans. Results are mixed in other populations, with no observational studies in a large multiethnic cohort. The association of serum 25(OH)D with diabetes may vary by adiposity level. RESEARCH DESIGN AND METHODS: Among 5611 participants in the Multi-Ethnic Study of Atherosclerosis without diabetes at baseline, cross-sectional associations of serum 25(OH)D with homeostasis model assessment of insulin resistance (HOMA-IR) and HOMA-ß were examined using linear regressions. The association of 25(OH)D with incident diabetes over 9 years was examined using Cox proportional hazard regression. RESULTS: Black Americans had the highest proportion of individuals with 25(OH)D<20 ng/mL (61%) and White Americans had the least (17%). Serum 25(OH)D was inversely associated with HOMA-IR in fully adjusted models (-0.34% difference in HOMA-IR per ng/mL higher 25(OH)D, p<0.0001). Longitudinally, a 1 ng/mL higher serum 25(OH)D was associated with 2% lower risk of incident diabetes (HR 0.982, CI 0.974 to 0.991), and a 1 pg/mL higher serum PTH was associated with 1% higher risk of incident diabetes (HR 1.007, CI 1.004 to 1.010), both prior to adjustment for waist circumference. After adjusting for waist circumference, a 1 ng/mL higher 25(OH)D was associated with 1% lower risk of incident diabetes (HR 0.991, CI 0.983 to 1.000). The magnitude of association of serum 25(OH)D with incident diabetes was largest at lower waist circumference (p for interaction=0.025). There was no heterogeneity by race/ethnicity (p=0.317). CONCLUSIONS: Serum 25(OH)D is inversely associated with insulin resistance and incident diabetes in a diverse cohort, including non-Hispanic White, Black, Hispanic and Chinese Americans. Future research should explore mechanisms for the interaction between serum 25(OH)D and adiposity in this relationship.

Glucometabolic State Transitions: The Jackson Heart Study.

Background: Diabetes and prediabetes are common among African Americans (AA), but the frequency and predictors of transition between normal, impaired glucose metabolism, and diabetes are not well-described. The aim of this study was to examine glucometabolic transitions and their association with the development of type 2 diabetes (T2D). Methods: AA participants of the Jackson Heart Study who attended baseline exam (2000-2004) and at least one of two subsequent exams (2005-2008 and 2009-2013, ~8 years) were classified according to glycemic status. Transitions were defined as progression (deterioration) or remission (improvement) of glycemic status. Multinomial logistic regression models with repeated measures were used to estimate the odds ratios (OR) for remission and progression with adjustment for demographic, anthropometric, behavioral, and biochemical factors. Results: Among 3353 participants, (mean age 54.6±12.3 years), 43% were normoglycemic, 32% were prediabetes, and 25% had diabetes at baseline. For those with normal glucose at a visit, the probability at the next visit (~4years) of having prediabetes or diabetes was 38.5% and 1.8%, respectively. For those with prediabetes, the probability was 9.9% to improve to normal and 19.9% to progress to diabetes. Progression was associated with baseline BMI, diabetes status, triglycerides, family history of diabetes, and weight gain (OR 1.04 kg, 95% CI:1.03-1.06, P=<.0001). Remission was strongly associated with weight loss (OR .97 kg, 95%CI: .95-.98, P<.001). Conclusions: In AAs, glucometabolic transitions were frequent and most involved deterioration. From a public health perspective additional emphasis should be placed on weight control to preserve glucometabolic status and prevent progression to T2D.

Racial and Ethnic Disparities in the Trends and Outcomes of Cardiogenic Shock Complicating Peripartum Cardiomyopathy.

Importance: Cardiogenic shock (CS) is a recognized complication of peripartum cardiomyopathy (PPCM) associated with poor prognosis. Although racial and ethnic disparities have been described in the occurrence and outcomes of PPCM, it is unclear if these disparities persist among patients with PPCM and CS. Objectives: To evaluate the temporal trends in CS incidence among hospitalized patients with PPCM stratified by race and ethnicity and to investigate the racial and ethnic differences in hospital mortality, mechanical circulatory support (MCS) use, and heart transplantation (HT). Design, Setting, and Participants: This multicenter retrospective cohort study included hospitalized patients with PPCM complicated by CS in the US from 2005 to 2019 identified from the National Inpatient Sample (NIS). Data analysis was conducted in November 2021. Exposure: PPCM complicated by CS. Main Outcomes and Measures: The main outcome was incidence of CS in PPCM stratified by race and ethnicity. The secondary outcome was racial and ethnic differences in hospital mortality, MCS use, and HT. Results: Of 55 804 hospitalized patients with PPCM, 1945 patients had CS, including 947 Black patients, 236 Hispanic patients, and 702 White patients, translating to an incidence rate of 35 CS events per 1000 patients with PPCM. The mean (SD) age was 31 (9) years. Black and Hispanic patients had higher CS incidence rates (39 events per 1000 patients with PPCM) compared with White patients (33 events per 1000 patients with PPCM). CS incidence rates significantly increased across all races and ethnicities over the study period. Overall, the odds of developing CS were higher in Black patients (aOR, 1.17 [95% CI, 1.15-1.57]; P < .001) and Hispanic patients (aOR, 1.37 [95% CI, 1.17-1.59]; P < 001) compared with White patients during the study period. Compared with White patients, the odds of in-hospital mortality were higher in Black (adjusted odds ratio [aOR], 1.67 [95% CI, 1.21-2.32]; P = .002) and Hispanic (aOR, 2.20 [95% CI, 1.45-3.33]; P < .001) patients. Hispanic patients were more likely to receive any type of MCS device (aOR, 2.23 [95% CI, 1.60-3.09]; P < .001), intraaortic balloon pump (aOR, 1.65 [95% CI, 1.11-2.44]; P < .001), and ventricular assisted device (aOR, 4.45 [95% CI, 2.45-8.08]; P < .001), compared with White patients. Black patients were more likely to receive VAD (aOR, 2.69 [95% CI, 1.63-4.42]; P < .001) compared with White patients. Black and Hispanic patients were significantly less likely to receive HT compared with White patients (Black patients: aOR, 0.51 [95% CI, 0.33-0.78]; P = .02; Hispanic patients: aOR, 0.15 [95% CI, 0.06-0.42]; P < .001). Conclusions and Relevance: These findings highlight significant racial disparities in mortality and HT among hospitalized patients with PPCM complicated by CS in the US. More research to identify factors of racial and ethnic disparities is needed to guide interventions to improve outcomes of patients with PPCM.

Determinants of Metabolic Syndrome and Type 2 Diabetes in the Absence of Obesity: The Jackson Heart Study.

Context: Multiple studies suggest that adults who were normal weight at diabetes diagnosis are at higher risk for all-cause mortality than those who had overweight or obesity at diagnosis. Objective: While obesity is a known risk factor for cardiometabolic disease, differences in body fat distribution in those without obesity are understudied, especially in African Americans. Methods: In 1005 participants of the Jackson Heart Study, without cardiovascular disease at baseline, we used logistic regression to investigate the longitudinal association of body fat distribution by CT scan with metabolic syndrome (MetS) or type 2 diabetes (T2D). We used the harmonized International Diabetes Federation criteria to define MetS. We included only normal weight or overweight participants (BMI: 18.5 to < 30.0 kg/m2). We created separate models for MetS and T2D adjusted for a standard set of covariates. We excluded participants with prevalent MetS or T2D, respectively in sensitivity. Results: Higher visceral fat, subcutaneous fat, BMI, and insulin resistance (HOMA-IR) were significantly associated with MetS and T2D after adjustment. Visceral fat was strongly associated with both outcomes (MetS OR = 2.07 [1.66-2.68]; T2D OR = 1.51 [1.21-1.88]), and the association for MetS persisted in the normal weight only group. Estimates were robust to sensitivity analysis and were only modestly mediated by insulin resistance. Physical activity was not associated with MetS or T2D. Conclusion: Visceral fat is strongly associated with developing MetS, even in normal weight individuals, suggesting that excess visceral fat plays a role in cardiometabolic risk beyond that of overall adiposity and obesity in African Americans.

Incidence and predictors of sudden cardiac arrest in the immediate post-percutaneous coronary intervention period for ST-elevation myocardial infarction: a single-center study.

BACKGROUND: Data on the incidence, predictors, and outcomes of sudden cardiac arrest (SCA) in the immediate post-percutaneous coronary intervention (PCI) period for ST-elevation myocardial infarction (STEMI) are limited. OBJECTIVES: The study aimed to investigate the trends and predictors of SCA occurring within 48 h post PCI for STEMI. METHODS: We systematically reviewed data from the electronic medical records of 403 patients who underwent PCI for STEMI between January 2014 and December 2019. Trends in the incidence of SCA 48 h post PCI for STEMI were assessed using the Cochrane-Armitage test. Multivariable logistic regression was used to determine the predictors of SCA within 48 h post PCI for STEMI. RESULTS: Of the 403 patients who underwent PCI for STEMI, 44 (11%) had SCA within 48 h post PCI. The incidence of SCA within 48 h post PCI decreased from 22% in 2014 to 8% in 2019; P = 0.03. After adjusting for underlying confounding variables in the multivariable logistic regression models, out of hospital cardiac arrest [adjusted odds ratio (aOR), 23.9; confidence interval (CI), 10.2-56.1], left main coronary artery disease (aOR, 3.1; CI, 1.1-9.4), left main PCI (aOR, 6.6; CI: 1.4-31.7), new-onset heart failure (aOR, 2.0; CI, 4.3-9.4), and cardiogenic shock (aOR, 5.8; CI, 1.7-20.2) were statistically significant predictors of SCA within 48 h post PCI for STEMI. CONCLUSION: We identified essential factors associated with SCA within 48 h post PCI for STEMI. Future studies are needed to devise effective strategies to decrease the risk of SCA in the early post-PCI period.

Intravascular Ultrasound-Guided Catheter-Based Aspiration Thrombectomy in Patients With Acute Submassive Pulmonary Embolism: A Case Series.

Contrast pulmonary angiography by hand injection or power injection is widely used during catheter-based therapies for acute submassive and massive pulmonary embolism (PE). Particularly, in patients with pre-existing chronic kidney disease, this approach may present a prognostic challenge owing to a double-contrast load, initially during computed tomographic pulmonary angiography (CTPA), and during percutaneous treatment. Intravascular ultrasound (IVUS) has been used as an adjunctive imaging modality in the percutaneous treatment of chronic thromboembolic pulmonary hypertension, and in coronary and peripheral vascular interventions. We report a series of cases illustrating the use of IVUS in the management of acute PE. All five patients presented with an acute submassive PE with evidence of right ventricular (RV) strain (RV/LV ratio ≥ 0.90). Body mass index and B-type natriuretic peptide ranged from 18 to 47 kgm/m2 and 56-932 pg/mL (ref. ≤ 78), respectively. Three of the five patients had renal impairment prior to the procedure (acute kidney injury, AKI, and chronic kidney injury, CKD). Post-catheter-directed pulmonary embolectomy there was a modest reduction in mean pulmonary artery pressure in all five patients (range: -4 mmHg to -9 mmHg). The first case serves as a proof of concept of IVUS use in acute PE. This case series demonstrates that an IVUS-only approach in the catheter-directed management of acute submassive PE is feasible and may be of particular importance in patients with pre-existing renal dysfunction.

Incidence and Severity of Depression Among Recovered African Americans with COVID-19-Associated Respiratory Failure.

BACKGROUND: Coronavirus disease (COVID-19) disproportionately affects African Americans, and they tend to experience more severe course and adverse outcomes. Using a simple and validated instrument of depression screening, we evaluated the incidence and severity of major depression among African American patients within 90 days of recovery from severe COVID-19-associated respiratory failure. METHODS: African American patients hospitalized and treated with invasive mechanical ventilation for COVID-19-associated respiratory failure in the intensive care unit (ICU) of Grady Memorial Hospital, Atlanta, between April 1, 2020, and June 30, 2020, were screened for depression within 90 days of hospital discharge using the validated patient health questionnaires (PHQ-2) and PHQ-9. RESULTS: A total of 73 patients completed the questionnaire. The median age was 52.5 years [IQR 44-65] and 65% were males. The most common comorbidities were hypertension (66%) and diabetes mellitus (51%). Forty-four percent of the patients had a diagnosis of major depressive disorder (MDD) based on their PHQ-9 questionnaire responses. The incidence of MDD was higher among females (69%, n=18/26) compared to males (29%, n=14/47), in patients > 75 years (66%) and those with multiple comorbidities (45%). Eighteen percent of the patients had moderate depression, while 15% and 22% had moderately severe and severe depression, respectively. Only 26% (n=7/27) of eligible patients were receiving treatment for depression at the time of this survey. CONCLUSION: The incidence of depression in a cohort of African American patients without prior psychiatric conditions who recovered from severe COVID-19 infection was 44%. More than 70% of these patients were not receiving treatment for depression.