Racial Disparities in Cardiovascular Risk and Cardiovascular Care in Women.

PURPOSE OF REVIEW: Research on sex and gender aspects cardiovascular disease has contributed to a reduction in cardiovascular mortality in women. However, cardiovascular disease remains the leading cause of death of women in the United States. Disparities in cardiovascular risk and outcomes among women overall persist and are amplified for women of certain ethnic and racial subgroups. We review the evidence of racial and ethnic differences in cardiovascular risk and care among women and describe a path forward to achieve equitable cardiovascular care for women of racial and ethnic minority groups. RECENT FINDINGS: There is a disproportionate effect on cardiovascular outcomes in women and certain racial and ethnic groups in part due to disparities in triage, diagnosis, treatment, which lead to amplification of inequalities in women of minority racial and ethnic background. Data suggest gender and racial bias, underappreciation of nontraditional risk factors, underrepresentation of women in clinical trials and undertreatment of disease contributes to persistent differences in cardiovascular disease outcomes in women of color. Understanding the myriad of factors that contribute to increased cardiovascular risk, and disparities in treatment and outcomes among women from racial/ethnic minority backgrounds is imperative to improving cardiovascular care for this patient population.

Functional mitral regurgitation in patients with heart failure and depressed ejection fraction.

PURPOSE OF REVIEW: Functional mitral regurgitation (FMR) is a common complication of left ventricular dysfunction. It is now recognized as an important clinical entity and an independent predictor of poor prognosis in cardiomyopathy patients. In this review, we provide a comprehensive summary of the pathophysiology, latest imaging modalities, and diagnostic criteria for FMR. Additionally, we discuss the recent literature on the continuously evolving surgical and percutaneous treatment options. RECENT FINDINGS: The criteria for quantification of FMR on echocardiography were updated and are distinct from organic mitral regurgitation in the most recent American College of Cardiology/American Heart Association 2014 valve guidelines. Furthermore, the evolving role of MitraClip for potential treatment of FMR offers exciting prospects to treat high-risk symptomatic patients. SUMMARY: Our review serves to consolidate the current diagnostic and treatment modalities for FMR and provide a contemporary resource for clinicians while treating patients. Additionally, we identify the gaps present in our knowledge of FMR to guide further clinical investigation.

Age- and sex-related features of atherosclerosis from coronary computed tomography angiography in patients prior to acute coronary syndrome: results from the ICONIC study.

AIMS: Although there is increasing evidence supporting coronary atherosclerosis evaluation by coronary computed tomography angiography (CCTA), no data are available on age and sex differences for quantitative plaque features. The aim of this study was to investigate sex and age differences in both qualitative and quantitative atherosclerotic features from CCTA prior to acute coronary syndrome (ACS). METHODS AND RESULTS: Within the ICONIC study, in which 234 patients with subsequent ACS were propensity matched 1:1 with 234 non-event controls, our current subanalysis included only the ACS cases. Both qualitative and quantitative advance plaque analysis by CCTA were performed by a core laboratory. In 129 cases, culprit lesions identified by invasive coronary angiography at the time of ACS were co-registered to baseline CCTA precursor lesions. The study population was then divided into subgroups according to sex and age (<65 vs. ≥ 65 years old) for analysis. Older patients had higher total plaque volume than younger patients. Within specific subtypes of plaque volume, however, only calcified plaque volume was higher in older patients (135.9 ± 163.7 vs. 63.8 ± 94.2 mm3, P < 0.0001, respectively). Although no sex-related differences were recorded for calcified plaque volume, females had lower fibrous and fibrofatty plaque volume than males (Fibrofatty volume 29.6 ± 44.1 vs. 75.3 ± 98.6 mm3, P = 0.0001, respectively). No sex-related differences in the prevalence of qualitative high-risk plaque features were found, even after separate analyses considering age were performed. CONCLUSION: Our data underline the importance of age- and sex-related differences in coronary atherosclerosis presentation, which should be considered during CCTA-based atherosclerosis quantification.

Constrictive Pericarditis Caused by IgG4-Related Disease Requiring Pericardiectomy After Partial Response to Corticosteroids.

Immunoglobulin G4-related disease is a systemic fibroinflammatory disease; pericardial involvement has occasionally been reported in publications. A 79-year-old man with biopsy-proven immunoglobulin G4-related disease with pleural involvement was admitted in acute heart failure, with imaging and hemodynamic studies consistent with constrictive pericarditis. He was treated with corticosteroids for 2 months with partial response manifest by decreases in pericardial thickening and immunoglobulin G4 levels. However, persistent constriction required pericardiectomy, leading to significant symptomatic improvement. (Level of Difficulty: Intermediate.).

Unusual Cause of Severe Tricuspid Regurgitation: Tricuspid Leaflet Annular Tear Following Remote Motor Vehicle Accident.

Tricuspid regurgitation (TR) is an uncommon and underdiagnosed complication of blunt chest trauma. Typical mechanisms include torn chordae, papillary muscle rupture, and radial leaflet tear. We describe an unusual case of traumatic TR due to circumferential avulsion of the anterior tricuspid leaflet from the tricuspid annulus and the crucial role of multimodality imaging in its diagnosis and treatment. (Level of Difficulty: Intermediate.).

Body mass index and peripheral artery disease.

BACKGROUND AND AIMS: An independent association of body mass index (BMI) with atherosclerotic cardiovascular disease is somewhat controversial and may differ by vascular bed. Sex-specific risk factors for atherosclerosis may further modify these associations. Obesity and peripheral artery disease (PAD) are both more prevalent in women. We sought to determine the association between PAD and BMI using a very large population-based study. METHODS: Self-referred individuals at >20,000 US sites completed medical questionnaires including height and weight, and were evaluated by screening ankle brachial indices (ABI) for PAD (ABI<0.9). RESULTS: Among 3,250,350 individuals, the mean age was 63.1 ±â€¯10.5 years and 65.5% were women. The mean BMI was 27.7 ±â€¯5.8 kg/m2. 27.8% of participants were obese (BMI ≥30 kg/m2) - 27.6% females, 28.1% males. Overweight individuals (BMI 25-29.9 kg/m2) exhibited the lowest prevalence of PAD. There was a J-shaped association of BMI with prevalent PAD. After adjustment for age and cardiovascular risk factors, underweight was associated with similarly increased odds of PAD (1.72 vs. 1.39, women and men, respectively). The association of obesity with PAD was predominant in women, with only a slight association of increasing BMI with PAD in men (OR = 2.98 vs. 1.37 for BMI ≥40 kg/m2). CONCLUSIONS: Our study suggests that increasing BMI is a robust independent risk factor for PAD only in women. This observation requires validation, but highlights the need for further research on sex-specific risk and mechanisms of atherosclerosis.

Evaluation of Atherosclerotic Plaque in Non-invasive Coronary Imaging.

Coronary artery disease (CAD) is the leading cause of morbidity and mortality worldwide. Over the last decade coronary computed tomography angiography (CCTA) has gained wide acceptance as a reliable, cost-effective and non-invasive modality for diagnosis and prognostication of CAD. Use of CCTA is now expanding to characterization of plaque morphology and identification of vulnerable plaque. Additionally, CCTA is developing as a non-invasive modality to monitor plaque progression, which holds future potential in individualizing treatment. In this review, we discuss the role of CCTA in diagnosis and management of CAD. Additionally, we discuss the recent advancements and the potential clinical applications of CCTA in management of CAD.

Prognosis of patients with secondary mitral regurgitation and reduced ejection fraction.

Objective: The impact of the severity of secondary mitral regurgitation (MR) on the risk of death and heart failure (HF) hospitalisations in patients with reduced left ventricular (LV) systolic function is poorly defined. The study sought to identify the incremental risk of secondary MR in patients with reduced LV systolic function. Methods: We studied 615 consecutive patients with LV ejection fraction ≤35% by transthoracic echocardiography at a single medical centre. Patients were divided into three groups of no MR, mild, or moderate to severe MR. The median follow-up was 2.9 years. The primary endpoint was a composite of death or HF hospitalisations. Results: Compared with patients with no MR, the risk of death or HF hospitalisations was higher for mild MR (HR 1.7, P=0.003) and moderate to severe MR (HR 2.7, P<0.001). The risk was also higher for the component endpoints of HF hospitalisations (mild MR: HR 2.3, P=0.001; moderate to severe MR: HR 3.5, P<0.001) and death (mild MR: HR 1.6, P=0.033; moderate to severe MR: HR 2.6, P<0.001). After adjustment for other covariates, MR was no longer significantly associated with death or HF hospitalisations, or death alone, but remained significantly associated with HF hospitalisations (mild MR: HR 1.7, P=0.028; moderate to severe MR: HR 2.2, P=0.002). Conclusions: In patients with reduced LV systolic function, secondary MR is associated with an increased risk of HF hospitalisations but not death.

Machine learning in cardiac CT: Basic concepts and contemporary data.

Propelled by the synergy of the groundbreaking advancements in the ability to analyze high-dimensional datasets and the increasing availability of imaging and clinical data, machine learning (ML) is poised to transform the practice of cardiovascular medicine. Owing to the growing body of literature validating both the diagnostic performance as well as the prognostic implications of anatomic and physiologic findings, coronary computed tomography angiography (CCTA) is now a well-established non-invasive modality for the assessment of cardiovascular disease. ML has been increasingly utilized to optimize performance as well as extract data from CCTA as well as non-contrast enhanced cardiac CT scans. The purpose of this review is to describe the contemporary state of ML based algorithms applied to cardiac CT, as well as to provide clinicians with an understanding of its benefits and associated limitations.

Maximization of the usage of coronary CTA derived plaque information using a machine learning based algorithm to improve risk stratification; insights from the CONFIRM registry.

INTRODUCTION: Machine learning (ML) is a field in computer science that demonstrated to effectively integrate clinical and imaging data for the creation of prognostic scores. The current study investigated whether a ML score, incorporating only the 16 segment coronary tree information derived from coronary computed tomography angiography (CCTA), provides enhanced risk stratification compared with current CCTA based risk scores. METHODS: From the multi-center CONFIRM registry, patients were included with complete CCTA risk score information and ≥3 year follow-up for myocardial infarction and death (primary endpoint). Patients with prior coronary artery disease were excluded. Conventional CCTA risk scores (conventional CCTA approach, segment involvement score, duke prognostic index, segment stenosis score, and the Leaman risk score) and a score created using ML were compared for the area under the receiver operating characteristic curve (AUC). Only 16 segment based coronary stenosis (0%, 1-24%, 25-49%, 50-69%, 70-99% and 100%) and composition (calcified, mixed and non-calcified plaque) were provided to the ML model. A boosted ensemble algorithm (extreme gradient boosting; XGBoost) was used and the entire data was randomly split into a training set (80%) and testing set (20%). First, tuned hyperparameters were used to generate a trained model from the training data set (80% of data). Second, the performance of this trained model was independently tested on the unseen test set (20% of data). RESULTS: In total, 8844 patients (mean age 58.0 ±â€¯11.5 years, 57.7% male) were included. During a mean follow-up time of 4.6 ±â€¯1.5 years, 609 events occurred (6.9%). No CAD was observed in 48.7% (3.5% event), non-obstructive CAD in 31.8% (6.8% event), and obstructive CAD in 19.5% (15.6% event). Discrimination of events as expressed by AUC was significantly better for the ML based approach (0.771) vs the other scores (ranging from 0.685 to 0.701), P < 0.001. Net reclassification improvement analysis showed that the improved risk stratification was the result of down-classification of risk among patients that did not experience events (non-events). CONCLUSION: A risk score created by a ML based algorithm, that utilizes standard 16 coronary segment stenosis and composition information derived from detailed CCTA reading, has greater prognostic accuracy than current CCTA integrated risk scores. These findings indicate that a ML based algorithm can improve the integration of CCTA derived plaque information to improve risk stratification.

Preclinical left ventricular diastolic dysfunction in metabolic syndrome.

Metabolic syndrome (MS) is commonly associated with left ventricular (LV) diastolic dysfunction and LV hypertrophy. We sought to examine whether preclinical LV diastolic dysfunction can occur independent of LV hypertrophy in MS. We recruited 90 consecutive participants with MS and without cardiovascular disease (mean age 46 years, 78% women) and 26 controls (no risk factors for MS; mean age 43 years, 65% women). Participants underwent echocardiography with tissue Doppler imaging. In age- and gender-adjusted analyses, MS was associated with higher left atrial (LA) diameter, higher LV mass, lower E/A ratio, and lower mean e' (p <0.001 for all). These associations remained significant after further adjusting for blood pressure, antihypertensive medication use, and body mass index. After adjusting for LV mass, MS remained independently associated with higher LA diameter, lower E/A ratio, and lower mean e' (p ≤0.01 for all). Specifically, subjects with MS had a 1.8 cm/s lower mean e' compared with controls (p = 0.01). Notably, differences in mean e' between those with and without MS were more pronounced at younger ages (p for interaction = 0.003). In conclusion, MS was associated with preclinical LV diastolic dysfunction independent of LV mass, as reflected by higher LA diameter, lower E/A ratio, and lower mean e'. This suggests that MS can lead to the development of diastolic dysfunction through mechanisms independent of hypertrophy. Differences in diastolic function were more pronounced at younger ages, highlighting the potential importance of early risk factor modification and preventive strategies in MS.