Environmental Exposome and Atrial Fibrillation: Emerging Evidence and Future Directions.

There has been increased awareness of the linkage between environmental exposures and cardiovascular health and disease. Atrial fibrillation is the most common sustained cardiac arrhythmia, affecting millions of people worldwide and contributing to substantial morbidity and mortality. Although numerous studies have explored the role of genetic and lifestyle factors in the development and progression of atrial fibrillation, the potential impact of environmental determinants on this prevalent condition has received comparatively less attention. This review aims to provide a comprehensive overview of the current evidence on environmental determinants of atrial fibrillation, encompassing factors such as air pollution, temperature, humidity, and other meteorologic conditions, noise pollution, greenspace, and the social environment. We discuss the existing evidence from epidemiological and mechanistic studies, critically evaluating the strengths and limitations of these investigations and the potential underlying biological mechanisms through which environmental exposures may affect atrial fibrillation risk. Furthermore, we address the potential implications of these findings for public health and clinical practice and identify knowledge gaps and future research directions in this emerging field.

The Urban Environment and Cardiometabolic Health.

Urban environments contribute substantially to the rising burden of cardiometabolic diseases worldwide. Cities are complex adaptive systems that continually exchange resources, shaping exposures relevant to human health such as air pollution, noise, and chemical exposures. In addition, urban infrastructure and provisioning systems influence multiple domains of health risk, including behaviors, psychological stress, pollution, and nutrition through various pathways (eg, physical inactivity, air pollution, noise, heat stress, food systems, the availability of green space, and contaminant exposures). Beyond cardiometabolic health, city design may also affect climate change through energy and material consumption that share many of the same drivers with cardiometabolic diseases. Integrated spatial planning focusing on developing sustainable compact cities could simultaneously create heart-healthy and environmentally healthy city designs. This article reviews current evidence on the associations between the urban exposome (totality of exposures a person experiences, including environmental, occupational, lifestyle, social, and psychological factors) and cardiometabolic diseases within a systems science framework, and examines urban planning principles (eg, connectivity, density, diversity of land use, destination accessibility, and distance to transit). We highlight critical knowledge gaps regarding built-environment feature thresholds for optimizing cardiometabolic health outcomes. Last, we discuss emerging models and metrics to align urban development with the dual goals of mitigating cardiometabolic diseases while reducing climate change through cross-sector collaboration, governance, and community engagement. This review demonstrates that cities represent crucial settings for implementing policies and interventions to simultaneously tackle the global epidemics of cardiovascular disease and climate change.

Artificial intelligence-based assessment of built environment from Google Street View and coronary artery disease prevalence.

BACKGROUND AND AIMS: Built environment plays an important role in the development of cardiovascular disease. Tools to evaluate the built environment using machine vision and informatic approaches have been limited. This study aimed to investigate the association between machine vision-based built environment and prevalence of cardiometabolic disease in US cities. METHODS: This cross-sectional study used features extracted from Google Street View (GSV) images to measure the built environment and link them with prevalence of coronary heart disease (CHD). Convolutional neural networks, linear mixed-effects models, and activation maps were utilized to predict health outcomes and identify feature associations with CHD at the census tract level. The study obtained 0.53 million GSV images covering 789 census tracts in seven US cities (Cleveland, OH; Fremont, CA; Kansas City, MO; Detroit, MI; Bellevue, WA; Brownsville, TX; and Denver, CO). RESULTS: Built environment features extracted from GSV using deep learning predicted 63% of the census tract variation in CHD prevalence. The addition of GSV features improved a model that only included census tract-level age, sex, race, income, and education or composite indices of social determinant of health. Activation maps from the features revealed a set of neighbourhood features represented by buildings and roads associated with CHD prevalence. CONCLUSIONS: In this cross-sectional study, the prevalence of CHD was associated with built environment factors derived from GSV through deep learning analysis, independent of census tract demographics. Machine vision-enabled assessment of the built environment could potentially offer a more precise approach to identify at-risk neighbourhoods, thereby providing an efficient avenue to address and reduce cardiovascular health disparities in urban environments.

Sex-specific heart failure burden across the United States: Global burden of disease 1990-2019.

BACKGROUND: Heart failure (HF) has unique aspects that vary by biological sex. Thus, understanding sex-specific trends of HF in the US population is crucial to develop targeted interventions. We aimed to analyze the burden of HF in female and male patients across the US, from 1990 to 2019. METHODS: Using the Global Burden of Disease (GBD) study data from 2019, we performed an analysis of the burden of HF from 1990-2019, across US states and regions. The GBD defined HF through studies that used symptom-based criteria and expressed the burden of HF as the age-adjusted prevalence and years lived with disability (YLDs) rates per 100,000 individuals. RESULTS: The age-adjusted prevalence of HF for the US in 2019 was 926.2 (95% UI [799.6, 1,079.0]) for females and 1,291.2 (95% UI [1,104.1, 1,496.8]) for males. Notably, our findings also highlight cyclic fluctuations in HF prevalence over time, with peaks occurring in the mid-1990s and around 2010, while reaching their lowest points in around 2000 and 2018. Among individuals >70 years of age, the absolute number of individuals with HF was higher in females, and this age group doubled the absolute count between 1990 and 2019. Comparing 1990-1994 to 2015-2019, 10 states had increased female HF prevalence, while only 4 states increased male prevalence. Overall, Western states had the greatest relative decline in HF burden, in both sexes. CONCLUSION: The burden of HF in the US is high, although the magnitude of this burden varies according to age, sex, state, and region. There is a significant increase in the absolute number of individuals with HF, especially among women >70 years, expected to continue due to the aging population.

Unfavorable social determinants of health and mortality risk by cardiovascular disease status: Findings from a National Study of United States Adults.

BACKGROUND: The association between cumulative burden of unfavorable social determinants of health (SDoH) and all-cause mortality has not been assessed by atherosclerotic cardiovascular disease (ASCVD) status on a population level in the United States. METHODS: We assessed the association between cumulative social disadvantage and all-cause mortality by ASCVD status in the National Health Interview Survey, linked to the National Death Index. RESULTS: In models adjusted for established clinical risk factors, individuals experiencing the highest level of social disadvantage (SDoH-Q4) had over 1.5 (aHR = 1.55; 95%CI = 1.22, 1.96) and 2-fold (aHR = 2.21; 95% CI = 1.91, 2.56) fold increased risk of mortality relative to those with the most favorable social profile (SDoH-Q1), respectively for adults with and without ASCVD; those experiencing co-occurring ASCVD and high social disadvantage had up to four-fold higher risk of mortality (aHR = 3.81; 95%CI = 3.36, 4.32). CONCLUSIONS: These findings emphasize the importance of a healthcare model that prioritizes efforts to identify and address key social and environmental barriers to health and wellbeing, particularly in individuals experiencing the double jeopardy of clinical and social risk.

Synthetic multi-contrast late gadolinium enhancement imaging using post-contrast magnetic resonance fingerprinting.

Late gadolinium enhancement (LGE) MRI is the non-invasive reference standard for identifying myocardial scar and fibrosis but has limitations, including difficulty delineating subendocardial scar and operator dependence on image quality. The purpose of this work is to assess the feasibility of generating multi-contrast synthetic LGE images from post-contrast T1 and T2 maps acquired using magnetic resonance fingerprinting (MRF). Fifteen consecutive patients with a history of prior ischemic cardiomyopathy (12 men; mean age 63  ±  13 years) were prospectively scanned at 1.5 T between Oct 2020 and May 2021 using conventional LGE and MRF after injection of gadolinium contrast. Three classes of synthetic LGE images were derived from MRF post-contrast T1 and T2 maps: bright-blood phase-sensitive inversion recovery (PSIR), black- and gray-blood T2 -prepared PSIR (T2 -PSIR), and a novel "tissue-optimized" image to enhance differentiation among scar, viable myocardium, and blood. Image quality was assessed on a 1-5 Likert scale by two cardiologists, and contrast was quantified as the mean absolute difference (MAD) in pixel intensities between two tissues, with different methods compared using Kruskal-Wallis with Bonferroni post hoc tests. Per-patient and per-segment scar detection rates were evaluated using conventional LGE images as reference. Image quality scores were highest for synthetic PSIR (4.0) and reference images (3.8), followed by synthetic tissue-optimized (3.3), gray-blood T2 -PSIR (3.0), and black-blood T2 -PSIR (2.6). Among synthetic images, PSIR yielded the highest myocardium/scar contrast (MAD = 0.42) but the lowest blood/scar contrast (MAD = 0.05), and vice versa for T2 -PSIR, while tissue-optimized images achieved a balance among all tissues (myocardium/scar MAD = 0.16, blood/scar MAD = 0.26, myocardium/blood MAD = 0.10). Based on reference mid-ventricular LGE scans, 13/15 patients had myocardial scar. The per-patient sensitivity/accuracy for synthetic images were the following: PSIR, 85/87%; black-blood T2 -PSIR, 62/53%; gray-blood T2 -PSIR, 100/93%; tissue optimized, 100/93%. Synthetic multi-contrast LGE images can be generated from post-contrast MRF data without additional scan time, with initial feasibility shown in ischemic cardiomyopathy patients.

Food Environment Quality and Cardiovascular Disease Mortality in the United States: a County-Level Analysis from 2017 to 2019.

BACKGROUND: Upstream socioeconomic circumstances including food insecurity and food desert are important drivers of community-level health disparities in cardiovascular mortality let alone traditional risk factors. The study assessed the association between differences in food environment quality and cardiovascular mortality in US adults. DESIGN: Retrospective analysis of the association between cardiovascular mortality among US adults aged 45 and above and food environment quality, measured as the food environment index (FEI), in 2615 US counties. FEI was measured by equal weights of food insecurity (limited access to a reliable food source) and food desert (limited access to healthy food), ranging from 0 (worst) to 10 (best). Age-adjusted cardiovascular mortality rates per 100,000 adults aged 45 and above in the calendar year 2017-2019. County-level association between CVD mortality rate and FEI was modeled using generalized linear regression. Data were weighted using county population. RESULT: Median CVD deaths per 100,000 population were 645.4 (IQR 561.5, 747.0) among adults aged 45 years and above across US counties in 2017-2019. About 12.8% (IQR 10.7%, 15.1%) of residents were food insecure and 6.3% (IQR 3.6%, 9.9%) were living in food desert areas. Comparing counties by FEI quartiles, the CVD mortality rate was higher in the least healthy FE counties (704.3 vs 598.6 deaths per 100,000 population) compared to the healthiest FE counties. One unit increase in FEI was associated with - 12.95 CVD deaths/100,000 population. In the subgroup analysis of counties with higher income inequality, the healthiest food environment was associated with 46.4 lower CVD deaths/100,000 population than the least healthy food environment. One unit increase in FEI in counties with higher income inequality was associated with a fivefold decrease in CVD mortality difference in African American counties (- 18.4 deaths/100,000 population) when compared to non-African American counties (- 3.63 deaths/100,000 population). CONCLUSION: In this retrospective multi-county study in the USA, a higher food environment index was significantly associated with lower cardiovascular mortality.

Social Phenotyping for Cardiovascular Risk Stratification in Electronic Health Registries.

PURPOSE OF REVIEW: Evaluation of social influences on cardiovascular care requires a comprehensive analysis encompassing economic, societal, and environmental factors. The increased utilization of electronic health registries provides a foundation for social phenotyping, yet standardization in methodology remains lacking. This review aimed to elucidate the primary approaches to social phenotyping for cardiovascular risk stratification through electronic health registries. RECENT FINDINGS: Social phenotyping in the context of cardiovascular risk stratification within electronic health registries can be separated into four principal approaches: place-based metrics, questionnaires, ICD Z-coding, and natural language processing. These methodologies vary in their complexity, advantages and limitations, and intended outcomes. Place-based metrics often rely on geospatial data to infer socioeconomic influences, while questionnaires may directly gather individual-level behavioral and social factors. Z-coding, a relatively new approach, can capture data directly related to social determinant of health domains in the clinical context. Natural language processing has been increasingly utilized to extract social influences from unstructured clinical narratives-offering nuanced insights for risk prediction models. Each method plays an important role in our understanding and approach to using social determinants data for improving population cardiovascular health. These four principal approaches to social phenotyping contribute to a more structured approach to social determinant of health research via electronic health registries, with a focus on cardiovascular risk stratification. Social phenotyping related research should prioritize refining predictive models for cardiovascular diseases and advancing health equity by integrating applied implementation science into public health strategies.

Elevated myocardial extracellular volume fraction is associated with the development of conduction pathway defects following transcatheter aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has become an established method of aortic stenosis treatment but suffers from the risk of heart block and pacemaker requirement. Risk stratification for patients who may develop heart block remains imperfect. Simultaneously, myocardial fibrosis as measured by cardiac magnetic resonance imaging (CMR) has been demonstrated as a prognostic indicator of ventricular recovery and mortality following TAVR. However, the association of CMR-based measures of myocardial fibrosis with post-TAVR conduction disturbances has not yet been explored. AIMS: We evaluated whether myocardial fibrosis, as measured by late gadolinium enhancement and extracellular volume (ECV) from CMR would be associated with new conduction abnormalities following TAVR. METHODS: One hundred seventy patients who underwent CMR within 2 months before TAVR were retrospectively reviewed. Septal late gadolinium enhancement (LGE) and ECV measurements were made as surrogates for replacement and interstitial fibrosis respectively. New conduction abnormalities were defined by the presence of transient or permanent atrioventricular block, new bundle branch blocks, and need for permanent pacemaker. Association of myocardial fibrosis and new conduction derangements were tested using receiver operator curve (ROC) and regression analysis in patients with and without pre-existing conduction issues. RESULTS: Forty-six (27.1%) patients developed post-TAVR conduction deficits. ECV was significantly higher among patients who experienced new conduction defects (26.2 ± 3.45% vs. 24.7% ± 4.15%, p value: 0.020). A greater fraction of patients that had new conduction defects had an elevated ECV of ≥26% (54.3% vs. 36.3%, p value: 0.026). ECV ≥ 26% was independently associated with the development of new conduction defects (odds ratio [OR]: 2.364, p value: 0.030). ROC analysis revealed a significant association of ECV with new conduction defects with an area under the receiver operating characteristic curve (AUC) of 0.632 (95% confidence interval: 0.555-0.705, p value: 0.005). The combination of prior right bundle branch block (RBBB) and ECV revealed a greater AUC of 0.779 (0.709-0.839, p value: <0.001) than RBBB alone (Delong p value: 0.049). No association of LGE/ECV with new conduction defects was observed among patients with pre-existing conduction disease. Among patients without baseline conduction disease, ECV was independently associated with the development of new conduction deficits (OR: 3.685, p value: 0.008). CONCLUSION: The present study explored the association of myocardial fibrosis, as measured by LGE and ECV with conduction deficits post-TAVR. Our results demonstrate an association of ECV, and thereby interstitial myocardial fibrosis, with new conduction derangement post-TAVR and introduce ECV as a potentially new risk stratification tool to identify patients at higher risk for needing post-TAVR surveillance and/or permanent pacemaker.

County-level socio-environmental factors and obesity prevalence in the United States.

AIMS: To investigate high-risk sociodemographic and environmental determinants of health (SEDH) potentially associated with adult obesity in counties in the United States using machine-learning techniques. MATERIALS AND METHODS: We performed a cross-sectional analysis of county-level adult obesity prevalence (body mass index ≥30 kg/m2) in the United States using data from the Diabetes Surveillance System 2017. We harvested 49 county-level SEDH factors that were used in a classification and regression trees (CART) model to identify county-level clusters. The CART model was validated using a 'hold-out' set of counties and variable importance was evaluated using Random Forest. RESULTS: Overall, we analysed 2752 counties in the United States, identifying a national median (interquartile range) obesity prevalence of 34.1% (30.2%, 37.7%). The CART method identified 11 clusters with a 60.8% relative increase in prevalence across the spectrum. Additionally, seven key SEDH variables were identified by CART to guide the categorization of clusters, including Physically Inactive (%), Diabetes (%), Severe Housing Problems (%), Food Insecurity (%), Uninsured (%), Population over 65 years (%) and Non-Hispanic Black (%). CONCLUSION: There is significant county-level geographical variation in obesity prevalence in the United States, which can in part be explained by complex SEDH factors. The use of machine-learning techniques to analyse these factors can provide valuable insights into the importance of these upstream determinants of obesity and, therefore, aid in the development of geo-specific strategic interventions and optimize resource allocation to help battle the obesity pandemic.

Continuous glucose monitoring for glycaemic control and cardiovascular risk reduction in patients with type 2 diabetes not on insulin therapy: A clinical trial.

AIM: To evaluate the impact of the Dexcom G6 continuous glucose monitoring (CGM) device on glycaemic control and cardiometabolic risk in patients with type 2 diabetes mellitus (T2DM) at high cardiovascular risk who are not on insulin therapy. MATERIALS AND METHODS: Adults with T2DM with glycated haemoglobin (HbA1c) >7% and body mass index (BMI) ≥30 kg/m2 not using insulin were enrolled in a two-phase cross-over study. In phase 1, CGM data were blinded, and participants performed standard glucose self-monitoring. In phase 2, the CGM data were unblinded, and CGM, demographic and cardiovascular risk factor data were collected through 90 days of follow-up and compared using paired tests. RESULTS: Forty-seven participants were included (44% women; 34% Black; mean age 63 years; BMI 37 kg/m2; HbA1c 8.4%; 10-year predicted atherosclerotic cardiovascular disease risk 24.0%). CGM use was associated with a reduction in average glucose (184.0 to 147.2 mg/dl, p < .001), an increase in time in range (57.8 to 82.8%, p < .001) and a trend towards lower glucose variability (26.2 to 23.8%). There were significant reductions in HbA1c, BMI, triglycerides, blood pressure, total cholesterol, diabetes distress and 10-year predicted risk for atherosclerotic cardiovascular disease (p < .05 for all) and an increase in prescriptions for sodium-glucose cotransporter 2 inhibitors (36.2 to 83.0%) and glucagon-like peptide-1 receptor agonists (42.5 to 87.2%, p < .001 for both). CONCLUSIONS: Dexcom G6 CGM was associated with improved glycaemic control and cardiometabolic risk in patients with T2DM who were not on insulin. CGM can be a safe and effective tool to improve diabetes management in patients at high risk for adverse cardiovascular outcomes.

The Society for Cardiovascular Magnetic Resonance Registry at 150,000.

OBJECTIVES: To summarize the status of the SCMR Registry at 150,000 exams. BACKGROUND: Cardiovascular magnetic resonance (CMR) is increasingly utilized to evaluate expanding cardiovascular conditions. The SCMR Registry is a central repository for real-world clinical data to support cardiovascular research, including those relating to outcomes, quality improvement, and machine learning. The SCMR Registry is built on a regulatory-compliant, cloud-based infrastructure that houses searchable content and Digital Imaging and Communications in Medicine (DICOM) images. METHODS: The processes for data security, data submission, and research access are outlined. We interrogated the Registry and present a summary of its contents. RESULTS: Data were compiled from 154,458 CMR scans across 20 United States sites, containing 299,622,066 total images (~100 terabytes of storage). The human subjects had an average age of 58 years (range 1 month to >90 years old), were 44% female, 72% Caucasian, and had a mortality rate of 8%. The most common indication was cardiomyopathy (27%), and most frequently used current procedural terminology (CPT) code was 75561 (35%). Macrocyclic gadolinium-based contrast agents represented 89% of contrast utilization after 2015. Short-axis cines were performed in 99% of scans, short-axis LGE in 66%, and stress perfusion sequences in 30%. Mortality data demonstrated increased mortality in patients with left ventricular ejection fraction (LVEF) < 35%, the presence of wall motion abnormalities, stress perfusion defects, and infarct late gadolinium enhancement (LGE), compared to those without these markers. There were 456,678 patient-years of all-cause mortality follow-up, with a median follow-up time of 3.6 years. CONCLUSIONS: The vision of the SCMR Registry is to promote evidence-based utilization of CMR through a collaborative effort by providing a web mechanism for centers to securely upload de-identified data and images for research, education, and quality control. The Registry quantifies changing practice over time and supports large-scale real-world multicenter observational studies of prognostic utility. CONDENSED ABSTRACT: The SCMR Registry is a central regulatory-compliant cloud-based repository for real-world clinical data and DICOM images for multicenter cardiovascular research, including outcomes-based data. The Registry contains 299,622,066 DICOM images and 456,678 patient-years follow-up. Data compiled from 154,458 CMR scans across 20 US sites demonstrated cardiomyopathy as the most common indication and 89% macrocyclic gadolinium contrast utilization after 2015. There was an overall mortality rate of 8%, with higher rates in those with LVEF<35%, abnormal wall motion, ischemia presence, or infarct LGE. The Registry aims to promote evidence-based CMR utilization through a collaborative effort to positively impact cardiovascular outcomes.

Trends in tracheal, bronchial and lung cancer attributed to smoking in South America: Global Burden of Disease analysis 1990-2019.

Objective: To investigate the burden of tracheal, bronchus, and lung (TBL) cancer due to tobacco exposure in the last 30 years in 12 South American countries. Methods: We used the Global Burden of Disease (GBD) 2019 exposure-response function to analyze the total tobacco, smoking, and secondhand smoke exposure-related TBL cancer deaths and disability-adjusted life years (DALYs), for 12 South American countries, between 1990 and 2019. Metrics were described as absolute numbers or rates per 100 000 individuals. The relative change in burden was assessed by comparing the 1990-1994 to 2015-2019 periods. Results: In 2019, the all-ages number of TBL cancer deaths and DALYs associated with tobacco exposure in South America was 29 348 and 658 204 in males and 14 106 and 318 277 in females, respectively. Age-adjusted death and DALYs rates for the region in 2019 were 182.8 and 4035 in males and 50.8 and 1162 in females, respectively. In males, 10/12 countries observed relative declines in TBL death rates attributed to tobacco exposure while only 4 countries reduced their mortality in females. Conclusion: While significant efforts on tobacco control are under place in South America, substantial burden of TBL cancer persists in the region with significant sex-specific disparities. Increased country-specific primary data on TBL cancer and tobacco exposure is needed to optimize healthcare strategies and improve comprehension of regional trends.

Low concentrations of medium-sized HDL particles predict incident CVD in chronic kidney disease patients.

Patients with chronic kidney disease (CKD) are at high risk for CVD. However, traditional CVD risk factors cannot completely explain the increased risk. Altered HDL proteome is linked with incident CVD in CKD patients, but it is unclear whether other HDL metrics are associated with incident CVD in this population. In the current study, we analyzed samples from two independent prospective case-control cohorts of CKD patients, the Clinical Phenotyping and Resource Biobank Core (CPROBE) and the Chronic Renal Insufficiency Cohort (CRIC). We measured HDL particle sizes and concentrations (HDL-P) by calibrated ion mobility analysis and HDL cholesterol efflux capacity (CEC) by cAMP-stimulated J774 macrophages in 92 subjects from the CPROBE cohort (46 CVD and 46 controls) and in 91 subjects from the CRIC cohort (34 CVD and 57 controls). We tested associations of HDL metrics with incident CVD using logistic regression analysis. No significant associations were found for HDL-C or HDL-CEC in either cohort. Total HDL-P was only negatively associated with incident CVD in the CRIC cohort in unadjusted analysis. Among the six sized HDL subspecies, only medium-sized HDL-P was significantly and negatively associated with incident CVD in both cohorts after adjusting for clinical confounders and lipid risk factors with odds ratios (per 1-SD) of 0.45 (0.22-0.93, P = 0.032) and 0.42 (0.20-0.87, P = 0.019) for CPROBE and CRIC cohorts, respectively. Our observations indicate that medium-sized HDL-P-but not other-sized HDL-P or total HDL-P, HDL-C, or HDL-CEC-may be a prognostic cardiovascular risk marker in CKD.

Coronary artery calcium scoring for cardiovascular risk assessment in patients with inflammatory bowel disease.

BACKGROUND: Inflammatory bowel disease (IBD) is associated with higher incidence of atherosclerotic cardiovascular disease (ASCVD). Data investigating the role of coronary artery calcium (CAC) scoring in identifying subclinical atherosclerotic disease in IBD patients is scarce. METHODS: Using data obtained from the CLARIFY registry, a prospective study of no-charge coronary artery calcium (CAC) testing at University Hospitals, we reviewed patients with ulcerative colitis (UC) or Crohn's disease (CD) who underwent CAC scoring from 2014 to 2020. We investigated the concordance between CAC risk and 10-year estimated ASCVD risk by AHA/ACC pooled cohort equation using pre-established thresholds for statin prescription (CAC≥100, 10-year ASCVD risk ≥7.5%). We additionally investigated the association between CAC, preventive therapy initiation and Major Adverse Cardiovascular Events (MACE). RESULTS: A total of 369 patients with IBD were included (174 UC, 195 CD), with median age of 60 years. The median CAC score was 14.9 with no significant difference between UC and CD (P = .76). Overall, 151 (41%) had CAC of 0, 108 (29%) had CAC 1-99, 61 (17%) had CAC 100 to 399, and 49 (13%) had CAC ≥400 with no difference in CAC distribution between CD and UC (P = .17). There was no difference in median CAC between IBD or age/sex-matched controls (P = .34). Approximately half of the patients (52%) with IBD had 10-year estimated ASCVD risk of 7.5% or higher. Among patients with ASCVD risk <7.5% (n = 163), 29 (18%) had CAC≥100 and among patients with ASCVD risk ≥7.5% (n = 178), 102 (57%) had CAC <100. There was no difference between CAC<100 vs CAC≥100 with respect to CRP, use of immunosuppressive or amino-salicylate therapy, IBD severity or complications. CAC score (AUROC 0.67 [0.56-0.78]), but not PCE ASCVD risk (AUROC 0.60 [0.48-0.73]), was predictive of MACE. The best cut-off for CAC score was 76 (sensitivity = 60%, specificity = 69%), and was associated with 4-fold increase in MACE (Hazard Ratio 4.0 [2.0-8.1], P < .001). CONCLUSION: Subclinical atherosclerosis, as evaluated by CAC scoring, is prevalent in patients with IBD, and is associated with cardiovascular events. Further studies are needed to understand underlying biological processes of increased atherosclerotic disease risk among adults with IBD.

Cardiac Structure and Function and Subsequent Kidney Disease Progression in Adults With CKD: The Chronic Renal Insufficiency Cohort (CRIC) Study.

RATIONALE & OBJECTIVE: Heart-kidney crosstalk is recognized as the cardiorenal syndrome. We examined the association of cardiac function and structure with the risk of kidney failure with replacement therapy (KFRT) in a chronic kidney disease (CKD) population. STUDY DESIGN: Prospective observational cohort study. SETTING & PARTICIPANTS: 3,027 participants from the Chronic Renal Insufficiency Cohort Study. EXPOSURE: Five preselected variables that assess different aspects of cardiac structure and function: left ventricular mass index (LVMI), LV volume, left atrial (LA) area, peak tricuspid regurgitation (TR) velocity, and left ventricular ejection fraction (EF) as assessed by echocardiography. OUTCOME: Incident KFRT (primary outcome), and annual estimated glomerular filtration rate (eGFR) slope (secondary outcome). ANALYTICAL APPROACH: Multivariable Cox models and mixed-effects models. RESULTS: The mean age of the participants was 59±11 SD years, 54% were men, and mean eGFR was 43±17mL/min/1.73m2. Between 2003 and 2018 (median follow-up, 9.9 years), 883 participants developed KFRT. Higher LVMI, LV volume, LA area, peak TR velocity, and lower EF were each statistically significantly associated with an increased risk of KFRT, with corresponding HRs for the highest versus lowest quartiles (lowest vs highest for EF) of 1.70 (95% CI, 1.27-2.26), 1.50 (95% CI, 1.19-1.90), 1.43 (95% CI, 1.11-1.84), 1.45 (95% CI, 1.06-1.96), and 1.26 (95% CI, 1.03-1.56), respectively. For the secondary outcome, participants in the highest versus lowest quartiles (lowest vs highest for EF) had a statistically significantly faster eGFR decline, except for LA area (ΔeGFR slope per year, -0.57 [95% CI, -0.68 to-0.46] mL/min/1.73m2 for LVMI, -0.25 [95% CI, -0.35 to-0.15] mL/min/1.73m2 for LV volume, -0.01 [95% CI, -0.12 to-0.01] mL/min/1.73m2 for LA area, -0.42 [95% CI, -0.56 to-0.28] mL/min/1.73m2 for peak TR velocity, and -0.11 [95% CI, -0.20 to-0.01] mL/min/1.73m2 for EF, respectively). LIMITATIONS: The possibility of residual confounding. CONCLUSIONS: Multiple aspects of cardiac structure and function were statistically significantly associated with the risk of KFRT. These findings suggest that cardiac abnormalities and incidence of KFRT are potentially on the same causal pathway related to the interaction between hypertension, heart failure, and coronary artery diseases. PLAIN-LANGUAGE SUMMARY: Heart disease and kidney disease are known to interact with each other. In this study, we examined whether cardiac abnormalities, as assessed by echocardiography, were linked to the subsequent progression of kidney disease among people living with chronic kidney disease (CKD). We found that people with abnormalities in heart structure and function had a greater risk of progression to advanced CKD that required kidney replacement therapy and had a faster rate of decline in kidney function. Our study indicates the potential role of abnormal heart structure and function in the progression of kidney disease among people living with CKD.

Red Cell Distribution Width and Absolute Lymphocyte Count Associate With Biomarkers of Inflammation and Subsequent Mortality in Rheumatoid Arthritis.

OBJECTIVE: Morbidity and mortality in rheumatoid arthritis (RA) is partly mitigated by maintaining immune and hematologic homeostasis. Identification of those at risk is challenging. Red cell distribution width (RDW) and absolute lymphocyte count (ALC) associate with cardiovascular disease (CVD) and mortality in the general population, and with disease activity in RA. How these variables relate to inflammation and mortality in RA was investigated. METHODS: In a retrospective single Veterans Affairs (VA) Rheumatology Clinic cohort of 327 patients with RA treated with methotrexate (MTX)+/- a tumor necrosis factor (TNF) inhibitor (TNFi), we evaluated RDW and ALC before and during therapy and in relation to subsequent mortality. Findings were validated in a national VA cohort (n = 13,914). In a subset of patients and controls, we evaluated inflammatory markers. RESULTS: In the local cohort, high RDW and low ALC prior to MTX treatment was associated with subsequent mortality over 10 years (both P < 0.001). The highest mortality was observed in those with both high RDW and low ALC. This remained after adjusting for age and comorbidities and was validated in the national RA cohort. In the immunology cohort, soluble and cellular inflammatory markers were higher in patients with RA than in controls. ALC correlated with age, plasma TNF receptor II, natural killer HLA-DR mean fluorescence intensity, and CD4CM/CD8CM HLA-DR/CD38%, whereas RDW associated with age and ALC. MTX initiation was followed by an increase in RDW and a decrease in ALC. TNFi therapy added to MTX resulted in an increase in ALC. CONCLUSION: RDW and ALC before disease-modifying antirheumatic drug therapy are associated with biomarkers of monocyte/macrophage inflammation and subsequent mortality. The mechanistic linkage between TNF signaling and lymphopenia found here warrants further investigation.

Management of a right coronary artery mycotic coronary aneurysm with percutaneous intervention with covered stents.

Coronary artery aneurysmal dilation is a rare finding with poorly understood mechanism of action that is found in small population of patients undergoing coronary angiography. Mycotic coronary aneurysm is an even rarer cause of coronary aneurysmal dilatation that develops as a potentially fatal complication of bacteremia. We present a case of mycotic right coronary artery aneurysm in a nonsurgical candidate with complex medical comorbidities treated with percutaneous coronary intervention via covered stents.

Neighbourhood-level social deprivation and the risk of recurrent heart failure hospitalizations in type 2 diabetes.

BACKGROUND: The importance of type 2 diabetes mellitus (T2D) in heart failure hospitalizations (HFH) is acknowledged. As information on the prevalence and influence of social deprivation on HFH is limited, we studied this issue in a racially diverse cohort. METHODS: Linking data from US Veterans with stable T2D (without prevalent HF) with a zip-code derived population-level social deprivation index (SDI), we grouped them according to increasing SDI as follows: SDI: group I: ≤20; II: 21-40; III: 41-60; IV: 61-80; and V (most deprived) 81-100. Over a 10-year follow-up period, we identified the total (first and recurrent) number of HFH episodes for each patient and calculated the age-adjusted HFH rate [per 1000 patient-years (PY)]. We analysed the incident rate ratio between SDI groups and HFH using adjusted analyses. RESULTS: In 1 012 351 patients with T2D (mean age 67.5 years, 75.7% White), the cumulative incidence of first HFH was 9.4% and 14.2% in SDI groups I and V respectively. The 10-year total HFH rate was 54.8 (95% CI: 54.5, 55.2)/1000 PY. Total HFH increased incrementally from SDI group I [43.3 (95% CI: 42.4, 44.2)/1000 PY] to group V [68.6 (95% CI: 67.8, 69.9)/1000 PY]. Compared with group I, group V patients had a 53% higher relative risk of HFH. The negative association between SDI and HFH was stronger in Black patients (SDI × Race pinteraction < .001). CONCLUSIONS: Social deprivation is associated with increased HFH in T2D with a disproportionate influence in Black patients. Strategies to reduce social disparity and equalize racial differences may help to bridge this gap.

Clinical impact of right ventricular pacing burden in patients with post-transcatheter aortic valve replacement permanent pacemaker implantation.

AIMS: Patients who undergo permanent pacemaker (PPM) implantation after transcatheter aortic valve replacement (TAVR) have a worse outcome. The aim of this study was to identify risk factors of worse outcomes in patients with post-TAVR PPM implantation. METHODS AND RESULTS: This is a single-centre, retrospective study of consecutive patients who underwent post-TAVR PPM implantation from 11 March 2011 to 9 November 2019. Clinical outcomes were evaluated by landmark analysis with cut-off at 1 year after the PPM implantation. Of the 1389 patients underwent TAVR during the study duration and a total of 110 patients were included in the final analysis. Right ventricular pacing burden (RVPB) ≥ 30% at 1 year was associated with a higher likelihood of heart failure (HF) readmission [adjusted hazard ratio (aHR): 6.333; 95% confidence interval [CI]: 1.417-28.311; P = 0.016] and composite endpoint of overall death and/or HF (aHR: 2.453; 95% CI: 1.040-5.786; P = 0.040). The RVPB ≥30% at 1 year was associated with higher atrial fibrillation burden (24.1 ± 40.6% vs. 1.2 ± 5.3%; P = 0.013) and a decrease in left ventricular ejection fraction (-5.0 ± 9.8% vs. + 1.1 ± 7.9%; P = 0.005). The predicting factors of the RVPB ≥30% at 1 year were the presence of RVPB ≥40% at 1 month and the valve implantation depth measured from non-coronary cusp ≥4.0 mm (aHR: 57.808; 95% CI: 12.489-267.584; P < 0.001 and aHR: 6.817; 95% CI: 1.829-25.402; P = 0.004). CONCLUSIONS: The RVPB ≥30% at 1 year was associated with worse outcomes. Clinical benefit of minimal RV pacing algorithms and biventricular pacing needs to be investigated.