Markers of Cardiovascular Risk Associated with Pregnancy.

PURPOSE OF REVIEW: The purpose of the review is to summarize the unique cardiovascular disease (CVD) risk factors encountered during pregnancy and to provide the reader with a framework for acquiring a comprehensive obstetric history during the cardiovascular (CV) assessment of women. RECENT FINDINGS: Individuals with a history of pregnancies complicated by hypertensive disorders of pregnancy (HDP), gestational diabetes (GDM), preterm delivery, low birth weight, and fetal growth restriction during pregnancy are at a higher risk of developing short- and long-term CV complications compared to those without adverse pregnancy outcomes (APOs). Women with a history of APOs can be at increased risk of CVD even after achieving normoglycemia and normal blood pressure control postpartum. Risk assessment and stratification in women must account for these APOs as recommended by the 2019 American College of Cardiology (ACC)/American Heart Association (AHA) guideline on the primary prevention of CVD. Early recognition, monitoring, and treatment of APOs are key to limiting CVD complications late in maternal life. Recognition of APOs as female-specific cardiovascular risk factors is critical for risk stratification for women and birthing persons. Further research is needed to understand the complex interplay between genetics, environmental, behavioral, and maternal vascular health, and the association between APOs and CVD risk.

Cardiac Surgery in Women in the Current Era: What Are the Gaps in Care?

Cardiovascular disease remains the leading cause of morbidity and mortality for women in United States and worldwide. One in 3 women dies from cardiovascular disease, and 45% of women >20 years old have some form of CVD. Historically, women have had higher morbidity and mortality after cardiac surgery. Sex influences pathogenesis, pathophysiology, presentation, postoperative complications, surgical outcomes, and survival. This review summarizes current cardiovascular surgery outcomes as they pertain to women. Specifically, this article seeks to address whether sex disparities in research, surgical referral, and outcomes still exist and to provide strategies to close these gaps. In addition, with the growing population of women of reproductive age with cardiovascular disease and cardiovascular risk factors, indications for cardiac surgery arise in pregnant women. The current review will also address the unique issues associated with this special population.

Social media to enhance engagement and science dissemination during in-person and virtual medical conferences: the SCMR 2020 and 2021 experiences: a report of the SCMR social media task force.

Most cardiac imaging conferences have adopted social media as a means of disseminating conference highlights to a global audience well beyond the confines of the conference location. A deliberate and thoughtful social media campaign has the potential to increase the reach of the conference and allow for augmented engagement. The coronavirus disease 2019 (COVID-19) pandemic triggered a radical transformation in not just the delivery of healthcare but also the dissemination of science within the medical community. In the past, in-person medical conferences were an integral annual tradition for most medical professionals to stay up to date with the latest in the field. Social distancing requirements of the COVID-19 pandemic resulted in either cancelling medical conferences or shifting to a virtual format. Following suit, for the first time in its history, the 2021 Society for Cardiovascular Magnetic Resonance (SCMR) annual meeting was an all-virtual event. This called for a modified social media strategy which aimed to re-create the sociability of an in-person conference whilst also promoting global dissemination of the science being presented. This paper describes the employment of social media as well as the evolution through the SCMR scientific sessions for 2020 and 2021 that serves as a model for future cardiovascular conferences.

Nuclear Cardiology in Women and Underrepresented Minority Populations.

PURPOSE OF REVIEW: To outline sex-specific features of coronary artery disease (CAD) that should be considered in the assessment of women, including those from ethnic minority populations with suspected stable ischemic heart disease (IHD). Second, to determine the latest nuclear imaging tools available to assess microvascular CAD. RECENT FINDINGS: Latest studies indicate that women are more likely to have ischemia with no obstructive coronary arteries (INOCA) and paradoxically have worse outcomes. Therefore, the evaluation of women with suspected IHD should include assessing microvascular and epicardial coronary circulation. The prevalence of CAD is increasing in younger women due to the increased cardiovascular disease (CVD) risk burden. CAD is often underrecognized in these patients. There is increasing recognition that INOCA is not benign and should be accurately diagnosed and managed. Nuclear imaging assesses the full spectrum of CAD from microvascular CAD to multivessel obstructive epicardial CAD. Further research on myocardial blood flow (MBF) assessment with PET MPI is needed.

The Role and Impact of Social Media in Cardio-oncology During the COVID-19 Pandemic.

PURPOSE OF REVIEW: To give an overview of the role of social media (SoMe) in cardio-oncology during the COVID-19 pandemic. RECENT FINDINGS: SoMe has been critical in fostering education, outreach, awareness, collaboration, dissemination of information, and advocacy in cardio-oncology. This has become increasingly evident during the COVID-19 pandemic, during which SoMe has helped share best practices, community, and research focused on the impact of COVID-19 in cardiology and hematology/oncology, with cardio-oncology at the interface of these two subspecialty fields. A strength of SoMe is the ability to amplify a message in real-time, globally, with minimal investment of resources. This has been particularly beneficial for the emerging field of cardio-hematology/cardio-oncology, a field focused on the interplay of cancer and cardiovascular disease. SoMe field especially during the COVID-19 pandemic. We illustrate how social media has supported innovation (including telemedicine), amplification of healthcare workers' voice, and illumination of pre-existing and continued health disparities within the field of cardio-oncology during the pandemic.

State of the Art in Noninvasive Imaging of Ischemic Heart Disease and Coronary Microvascular Dysfunction in Women: Indications, Performance, and Limitations.

PURPOSE OF REVIEW: Establishing a diagnosis of ischemic heart disease (IHD) in women, including assessment for coronary microvascular dysfunction (CMD) when indicated, can be challenging. Access to performance of invasive testing when appropriate may be limited, and noninvasive imaging assessments have evolved. This review will summarize the various noninvasive imaging modalities available for the diagnosis of IHD and CMD in women, outlining indications, performance modalities, advantages, and limitations. RECENT FINDINGS: While stress echocardiography and single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) are widely available and can detect IHD in women, their ability to specifically identify CMD is limited. Novel developments in cardiac magnetic resonance (CMR) imaging, including spectroscopy, and positron emission tomography (PET) have changed the diagnostic landscape. Coronary computed tomographic angiography (CCTA), while unable to diagnose CMD, is developing an emerging role in the risk stratification of ischemic syndromes. Despite the discovery of increased CMD prevalence in symptomatic women and technological advances in diagnostic imaging, practitioners are limited by user expertise and center availability when choosing a diagnostic imaging modality. Knowledge of this evolving field is imperative as it highlights the need for sex-specific assessment of cardiovascular syndromes.

The voyage: Amalgating a social media platform through the annual scientific meeting.

Social media platforms are increasingly used by professional societies for improved member engagement, to raise awareness, for advocacy and for widespread dissemination of scientific meeting highlights. This article describes the inaugural social media campaign implemented at the American Society of Nuclear Cardiology (ASNC) 2019 Scientific Meeting. Campaign strategies, including development of an interactive social media curriculum, dedicated social media ambassadors and implementation and announcement of a Tweetup, are described in detail. These efforts resulted in significantly uplifting the profile of the conference, improving attendee engagement, reinforced conference highlights, and expanded meeting reach across the world. This manuscript provides a blueprint for other professional societies considering the launch of a Social Media campaign at their scientific meetings.

Heart Centers for Women: Historical Perspective on Formation and Future Strategies to Reduce Cardiovascular Disease.

Heart Centers for Women (HCW) developed as a response to the need for improved outcomes for women with cardiovascular disease (CVD). From 1984 until 2012, more women died of CVD every single year in comparison with men. Initially, there was limited awareness and sex-specific research regarding mortality or outcomes in women. HCW played an active role in addressing these disparities, provided focused care for women, and contributed to improvements in these gaps. In 2014 and 2015, death from CVD in women had declined below the level of death from CVD in comparison with men. Even though awareness of CVD in women has increased among the public and healthcare providers and both sex- and gender-specific research is currently required in all research trials, not all women have benefitted equally in mortality reduction. New strategies for HCW need to be developed to address these disparities and expand the current HCW model. The HCW care team needs to direct academic curricula on sex- and gender-specific research and care; expand to include other healthcare professionals and other subspecialties; provide new care models; address diversity; and include more male providers.

Simultaneous determination of dynamic cardiac metabolism and function using PET/MRI.

BACKGROUND: Cardiac metabolic changes in heart disease precede overt contractile dysfunction. However, metabolism and function are not typically assessed together in clinical practice. The purpose of this study was to develop a cardiac positron emission tomography/magnetic resonance (PET/MR) stress test to assess the dynamic relationship between contractile function and metabolism in a preclinical model. METHODS: Following an overnight fast, healthy pigs (45-50 kg) were anesthetized and mechanically ventilated. 18F-fluorodeoxyglucose (18F-FDG) solution was administered intravenously at a constant rate of 0.01 mL/s for 60 minutes. A cardiac PET/MR stress test was performed using normoxic gas (FIO2 = .209) and hypoxic gas (FIO2 = .12). Simultaneous cardiac imaging was performed on an integrated 3T PET/MR scanner. RESULTS: Hypoxic stress induced a significant increase in heart rate, cardiac output, left ventricular (LV) ejection fraction (EF), and peak torsion. There was a significant decline in arterial SpO2, LV end-diastolic and end-systolic volumes in hypoxia. Increased LV systolic function was coupled with an increase in myocardial FDG uptake (Ki) during hypoxic stress. CONCLUSION: PET/MR with continuous FDG infusion captures dynamic changes in both cardiac metabolism and contractile function. This technique warrants evaluation in human cardiac disease for assessment of subtle functional and metabolic abnormalities.

Reduced regional flow in the left ventricle after anterior acute myocardial infarction: a case control study using 4D flow MRI.

BACKGROUND: Acute myocardial infarction (AMI) alters left ventricular (LV) hemodynamics, resulting in decreased global LV ejection fraction and global LV kinetic energy. We hypothesize that anterior AMI effects localized alterations in LV flow and developed a regional approach to analyze these local changes with 4D flow MRI. METHODS: 4D flow cardiac magnetic resonance (CMR) data was compared between 12 anterior AMI patients (11 males; 66 ± 12yo; prospectively acquired in 2016-2017) and 19 healthy volunteers (10 males; 40 ± 16yo; retrospective from 2010 to 2011 study). The LV cavity was contoured on short axis cine steady-state free procession CMR and partitioned into three regions: base, mid-ventricle, and apex. 4D flow data was registered to the short axis segmentation. Peak systolic and diastolic through-plane flows were compared region-by-region between groups using linear models of flow with age, sex, and heart rate as covariates. RESULTS: Peak systolic flow was reduced in anterior AMI subjects compared to controls in the LV mid-ventricle (fitted reduction = 3.9 L/min; P = 0.01) and apex (fitted reduction = 1.4 L/min; P = 0.02). Peak diastolic flow was also lower in anterior AMI subjects compared to controls in the apex (fitted reduction = 2.4 L/min; P = 0.01). CONCLUSIONS: A regional method to analyze 4D LV flow data was applied in anterior AMI patients and controls. Anterior AMI patients had reduced regional flow relative to controls.

Sex-Specific Differences in Ventricular Dimensions in Repaired Tetralogy of Fallot: A Retrospective Study.

The timing of pulmonary valve replacement (PVR) in asymptomatic patients with repaired tetralogy of Fallot (TOF) is typically based on cardiac magnetic resonance imaging-derived ventricular volume measurements. Current criteria do not account for sex-based differences in chamber size. The purpose of this study was to compare male and female ventricular volumes and function in TOF patients with a hypothesis that females are less likely to meet common-indexed right ventricular end-diastolic volume (RVEDVi) and right ventricular end-systolic volume (RVESVi) criteria for PVR. Cardiac magnetic resonance data from 17 females (age 31.7 ± 15.4 years) and 23 males (30.7 ± 15.4 years) with TOF were retrospectively analyzed. Demographic and imaging data were recorded. Differences in sex-based means and standard deviations were evaluated using the Wilcoxon rank-sum test with continuity correction. Age and pulmonary regurgitant fraction were similar in females and males. RVEDVi was lower in females than in males, but the difference was not statistically significant. Differences in RVESVi, LVEDVi, LVESVi, and left ventricular ejection fraction were statistically significant, while the difference in right ventricular ejection fraction was not. RVEDVi was greater than 150 mL/m2 in 3/17 (17.6%) females and 10/23 (43.5%) males (OR 3.6). RVESVi was greater than 82 mL/m2 in 2/17 females and 8/23 males (OR 4.0). Sex-specific differences in right ventricular and left ventricular volumes and function are present in patients with TOF despite similar pulmonary regurgitation. These differences may need to be considered when evaluating patients for PVR.

Pharmacodynamic Comparison of Prasugrel Versus Ticagrelor in Patients With Type 2 Diabetes Mellitus and Coronary Artery Disease: The OPTIMUS (Optimizing Antiplatelet Therapy in Diabetes Mellitus)-4 Study.

BACKGROUND: Patients with diabetes mellitus (DM) are at increased risk of atherothrombotic events, underscoring the importance of effective platelet inhibiting therapies. Prasugrel and ticagrelor reduce thrombotic complications to a greater extent than clopidogrel. Subgroup analyses of pivotal clinical trials testing prasugrel and ticagrelor versus clopidogrel showed DM patients to have benefits that were consistent with the overall trial populations, although the magnitude of the ischemic risk reduction appeared to be enhanced with prasugrel. Whether these findings may be attributed to differences in the pharmacodynamic profiles of these drugs in DM patients remains poorly explored and represented the aim of this study. METHODS: In this prospective, randomized, double-blind, double-dummy, crossover pharmacodynamic study, aspirin-treated DM patients (n=50) with coronary artery disease were randomly assigned to receive prasugrel (60 mg loading dose [LD]/10 mg maintenance dose once daily) or ticagrelor (180 mg LD/90 mg maintenance dose twice daily) for 1 week. Pharmacodynamic assessments were conducted using 4 different assays, including VerifyNow P2Y12, vasodilator-stimulated phosphoprotein, light transmittance aggregometry, and Multiplate, which allowed us to explore ADP- and non-ADP-induced (arachidonic acid-, collagen-, thrombin receptor-activating, peptide-induced) platelet signaling pathways. The acute (baseline, 30 minutes, and 2 hours post-LD) and maintenance (1 week) effects of therapy were assessed. The primary end point of the study was the comparison of P2Y12 reaction units determined by VerifyNow P2Y12 at 1 week between prasugrel and ticagrelor. RESULTS: ADP- and non-ADP-induced measures of platelet reactivity reduced significantly with both prasugrel and ticagrelor LD and maintenance dose. P2Y12 reaction units defined by VerifyNow were similar between prasugrel and ticagrelor at 30 minutes and 2 hours post-LD. At 1 week, P2Y12 reaction units were significantly lower with ticagrelor than with prasugrel (52 [32-72] versus 83 [63-103]; least-square means difference: -31; 95% confidence interval, -57 to -4; P=0.022; primary end point). Pharmacodynamic assessments measured by vasodilator-stimulated phosphoprotein, light transmittance aggregometry, and Multiplate were similar between prasugrel and ticagrelor at each time point, including at 1 week. Rates of high on-treatment platelet reactivity were similar between groups with all assays at all time points. CONCLUSIONS: In DM patients with coronary artery disease, ticagrelor exerts similar or greater inhibition of ADP-induced platelet reactivity in comparison with prasugrel in the acute and chronic phases of treatment, whereas the inhibition of measures of non-ADP-induced platelet reactivity was not significantly different between the 2 agents. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01852214.

Feasibility and diagnostic accuracy of exercise treadmill nitrogen-13 ammonia PET myocardial perfusion imaging of obese patients.

BACKGROUND: Treadmill exercise nitrogen-13 ((13)N)-ammonia positron emission tomography (PET) has logistical challenges and limited literature. We aimed to assess its feasibility, image quality, and diagnostic accuracy in obese and nonobese patients. METHODS AND RESULTS: Between 2009 and 2012, 10,804 patients were referred for myocardial perfusion imaging, including 300 for treadmill PET, of whom 265 were included in this study. Treadmill testing and PET were performed using standard procedures. Image quality, perfusion, and summed stress score (SSS) were assessed. Invasive coronary angiography was performed within 90 days of PET in 43 patients. Mean ± SD body mass index (BMI) was 35.7 ± 7.7 kg/m(2) (range 19.5-63.5 kg/m(2)). Feasibility of treadmill (13)N-ammonia PET was 100%. Exercise duration was less for obese patients than nonobese patients (P < .001). Image quality was rated good for 96.9% of obese and 100% of nonobese patients. For all patients, sensitivity was 86.4% and specificity was 74.4%. Diagnostic accuracy did not change significantly with increasing BMI. SSS remained significant in predicting angiographic coronary artery disease after adjustment for age, sex, and Duke treadmill score. CONCLUSIONS: Treadmill (13)N-ammonia PET is highly feasible, yields good image quality, and has moderately high diagnostic accuracy in a small subset of obese and nonobese patients who are deemed able to perform treadmill exercise.

Cardiovascular Disease in Hispanic Women: JACC Review Topic of the Week.

Cardiovascular disease affects 37% of Hispanic women and is the leading cause of death among Hispanic women in the United States. Hispanic women have a higher burden of cardiovascular risk factors, are disproportionally affected by social determinants of health, and face additional barriers related to immigration, such as discrimination, language proficiency, and acculturation. Despite this, Hispanic women show lower rates of cardiovascular disease and mortality compared with non-Hispanic White women. However, this "Hispanic paradox" is challenged by recent studies that account for the diversity in culture, race, genetic background, country of origin, and social determinants of health within Hispanic subpopulations. This review provides a comprehensive overview of the cardiovascular risk factors in Hispanic women, emphasizing the role of social determinants, and proposes a multipronged approach for equitable care.

Recommendations for the Management of High-Risk Cardiac Delivery: ACC Cardiovascular Disease in Women Committee Panel.

Maternal mortality is a major public health crisis in the United States. Cardiovascular disease (CVD) is a leading cause of maternal mortality and morbidity. Labor and delivery is a vulnerable time for pregnant individuals with CVD but there is significant heterogeneity in the management of labor and delivery in high-risk patients due in part to paucity of high-quality randomized data. The authors have convened a multidisciplinary panel of cardio-obstetrics experts including cardiologists, obstetricians and maternal fetal medicine physicians, critical care physicians, and anesthesiologists to provide a practical approach to the management of labor and delivery in high-risk individuals with CVD. This expert panel will review key elements of management from mode, timing, and location of delivery to use of invasive monitoring, cardiac devices, and mechanical circulatory support.