Search

Cardiovascular disease is the leading cause of death worldwide. Given the increased availability of radiopharmaceuticals, improved positron emission tomography (PET) camera systems and proven higher diagnostic accuracy, PET is increasingly utilized in the management of various cardiovascular diseases. PET has high temporal and spatial resolution, when compared to Single Photon Emission Computed Tomography. In clinical practice, hybrid imaging with sequential PET and Computed Tomography acquisitions (PET/CT) or concurrent PET and Magnetic Resonance Imaging are standard. This article will review applications of cardiovascular PET/CT including myocardial perfusion, viability, cardiac sarcoidosis/inflammation, and infection.

Introduction In 2017, the American College of Cardiology/American Heart Association revised guidelines for diagnosis and management of hypertension in adults. The regional impact of the updated guidelines on the prevalence of hypertension in India is unknown. Methods Data from nationally representative Indian households were analyzed to estimate the regional prevalence of hypertension according to the old and the new guidelines in men (age 18-54 years) and women (age 18-49 years). The old guidelines defined hypertension as a systolic blood pressure of ≥140 mmHg or diastolic blood pressure of ≥90 mmHg or treatment. The new guidelines define hypertension as a systolic blood pressure of ≥130 mmHg or diastolic blood pressure of ≥80 mmHg or treatment. We calculated the increase in the prevalence of hypertension among the states and union territories of India (hereafter "states"). Results Among 679,712 participants (85.6% women), the median age was 31 years (interquartile range 24, 40) and was comparable among men and women (33 vs. 31 years, respectively). The overall weighted prevalence according to old and new guidelines was 18.5% (95% CI 18.2, 18.7) and 43.0% (95% CI 42.8, 43.3), respectively. There was a significant increase in hypertension prevalence, both among men and women, and across all regions. The northeast region of the country had the highest prevalence. Conclusion The overall prevalence of hypertension significantly increases with the new compared to the old guidelines, however, the regional heterogeneity of prevalence of hypertension is maintained.

The ECG findings during sudden collapse (syncope or sudden death) in severe aortic stenosis (AS) are not well defined. We conducted a comprehensive review of the literature for ECG data during sudden collapse in patients with AS and provided a case report of our own. There were 37 published cases of syncope or sudden death in patients with severe AS which were documented by ECG. Brady- or ventricular arrhythmias were documented in 34 cases (92%). Bradyarrhythmia (n = 24; 71%) was more common at the time of collapse than ventricular tachyarrhythmia (n = 10; 29%). There was slowing of the sinus rate before bradyarrhythmia in the vast majority of patients with bradyarrhythmia but not in those presenting with ventricular tachyarrhythmia (75% vs 0%; p0.001). ECG evidence of ischemia (ST-segment depression or elevation) was present in most patients with bradyarrhythmia but not in those with ventricular tachyarrhythmia (75% vs 0%; p = 0.011). In conclusion, our findings suggest that left ventricular baroreceptor activation plays a dominant role in the pathophysiology of sudden collapse in patients with severe AS and suggest that ischemia may play a role as well.

Aims Immunomodulation in heart failure (HF) has been studied in several randomized controlled trials (RCTs) with variable effects on cardiac structure, function, and outcomes. We sought to determine the effect of immunomodulation on left ventricular ejection fraction (LVEF), LV end‐diastolic dimension (LVEDD), and all‐cause mortality in patients with HF with reduced ejection fraction (HFrEF) through meta‐analyses and trial sequential analyses (TSAs) of RCTs. Methods and results PubMed, Embase®, Cochrane CENTRAL, and http://ClinicalTrials.gov were systematically reviewed to identify RCTs that studied the effects of immunomodulation in patients with HFrEF. The primary endpoint in this analysis was change in LVEF. Secondary outcomes were changes in LVEDD and all‐cause mortality. TSA was used to quantify the statistical reliability of data in the cumulative meta‐analyses. Nineteen RCTs with 1341 HFrEF subjects were eligible for analyses. The aetiology of HF, specific immunomodulation strategy, and treatment duration were variable across trials. Immunomodulation led to a greater improvement in LVEF [mean difference: +5.7% 95% confidence interval (CI): 3.0–8.5%, P < 0.001] and reduction in LVEDD (mean difference: −3.7 mm, 95% CI: −7.0 to −0.4 mm, P = 0.028) than no immunomodulation in meta‐analyses and TSAs. We observed a non‐significant decrease in all‐cause mortality among those on immumomodulation (risk ratio: 0.7, 95% CI: 0.4–1.3, P = 0.234), but the Z‐curve for cumulative treatment effect of immunomodulation in the TSA did not cross the boundary of futility. Conclusions Immunomodulation led to improved cardiac structure and function in patients with HFrEF. While these benefits did not translate into a significant improvement in mortality, our analysis suggests that larger studies of targeted immunomodulation are needed to understand the true benefits.

Visual Abstract, Highlights • Extensive LA fibrosis is related to an increase in LA size and decrease in total LA EF. This supports the contention that the LA is not merely a bystander of MR but rather is actively involved in the pathophysiology of MR. • Chymase is plentiful in the human heart, especially in the LA, and correlates with extracellular matrix accumulation in primary MR. • Because of the unreliability of the LV ejection fraction in primary MR, future studies may consider LA size and total LA EF for timing of surgical intervention of asymptomatic moderate to severe MR., Summary Increasing left atrial (LA) size predicts outcomes in patients with isolated mitral regurgitation (MR). Chymase is plentiful in the human heart and affects extracellular matrix remodeling. Chymase activation correlates to LA fibrosis, LA enlargement, and a decreased total LA emptying fraction in addition to having a potential intracellular role in mediating myofibrillar breakdown in LA myocytes. Because of the unreliability of the left ventricular ejection fraction in predicting outcomes in MR, LA size and the total LA emptying fraction may be more suitable indicators for timing of surgical intervention.

Marijuana use is increasing as more states are legalizing cannabis for both medicinal and recreational purposes. National survey data estimate that >2 million Americans with established cardiovascular diseases currently use or have used marijuana in its variety of forms, including inhalation and vaping. Cannabinoid receptors are distributed in multiple tissue beds and cells, including platelets, adipose tissue, and myocytes. Observational data suggest associations between marijuana and a broad range of adverse cardiovascular risks. Marijuana is becoming increasingly potent, and smoking marijuana carries many of the same cardiovascular health hazards as smoking tobacco. Synthetic cannabinoids have been linked to more sustained and deleterious pharmacodynamic effects. Marijuana is classified as a Schedule I substance, thus limiting its rigorous study for cardiovascular health effects. This review summarizes cardiovascular considerations related to marijuana use, pharmacological interactions, and future steps to provide clearer guidance regarding its cardiovascular safety. Screening for marijuana use is encouraged, especially in young patients presenting with cardiovascular disease.

Objectives: With recent advances in left ventricular assist device (LVAD) technology, the utilization of LVADs has increased while mortality, cost, and length of stay (LOS) have significantly decreased. This study sought to determine the national trends of surgically implanted biventricular assist devices (BiVADs). Methods: This is a retrospective analysis of the National Inpatient Sample (NIS) database for internal BiVADs (n = 538) and external BiVADs (n = 727) from 2009 to 2015. Results: Utilization of all surgically implanted BiVADs decreased (4.8% per year, p < 0.001), and was driven by a decline in utilization of external BiVADs (9.4% per year, p < 0.001). There was no significant change in BiVAD-associated mortality. However, cost and LOS increased significantly, and these trends were isolated to patients who died during their hospitalization. Patients with internal BiVADs incurred higher cost than external BiVAD patients but were more likely to survive. Conclusions: The decline in surgically implanted BiVAD utilization may be due to an improvement in LVAD technology as well as an increase in the availability of percutaneous temporary circulatory support. Future prospective studies are needed to compare various BiVAD configuration strategies and to optimize BiVAD patient selection and perioperative care.

OBJECTIVES: The authors aimed to study the sensitivity and specificity of exercise treadmill testing (ETT) in the diagnosis of coronary microvascular disease (CMD), as well as the prognostic implications of ETT results in patients with CMD. BACKGROUND: ETT is validated to evaluate for flow-limiting coronary artery disease (CAD), however, little is known about its use for evaluating CMD. METHODS: We retrospectively studied 249 consecutive patients between 2006 and 2016 who underwent ETT and positron emission tomography within 12 months. Patients with obstructive CAD or left ventricular systolic dysfunction were excluded. CMD was defined as a coronary flow reserve

BACKGROUND: Gallium-68 Dotatate binds preferentially to somatostatin receptor (sstr) subtype-2 (sstr-2) on inflammatory cells. We aimed at investigating the potential clinical use of sstr-targeted imaging for the detection of myocardial inflammation. METHODS: 13 patients with suspected cardiac sarcoidosis (CS) based on clinical history and myocardial uptake on recent fluorine-18 fluorodeoxyglucose (FDG) PET, were enrolled to undergo Dotatate PET after FDG PET (median time 37 days [IQR 25 – 55]). Additionally, we investigated ex-vivo the immunohistochemistry expression of sstr-2 in 3 explanted sarcoid hearts. RESULTS: All FDG scans showed cardiac uptake (focal/multifocal = 6, focal on diffuse/heterogeneous = 7), and 46% (n=6) extra-cardiac uptake (mediastinal/hilar). In comparison, Dotatate scans showed definite abnormal cardiac uptake (focal/multifocal) in 4 patients, probably abnormal (heterogenous/patchy) in 3, and negative uptake in 6 cases. Similarly, 6 patients had increased mediastinal/hilar Dotatate uptake. Overall concordance of FDG and Dotatate uptake was 54% in the heart and 100% for thoracic nodal activity. Quantitatively, FDG maximum standardized uptake value was 5.0 times [3.8 – 7.1] higher in the heart, but only 2.25 times [1.7 – 3.0; P=0.019] higher in thoracic nodes relative to Dotatate. Ex-vivo, sstr-2 immunostaining was weakly seen within well-formed granulomas in all 3 examined sarcoid heart specimens with no significant staining of background myocardium or normal myocardium. CONCLUSION: Our preliminary data suggests that, compared to FDG imaging, somatostatin receptor-targeted imaging may be less sensitive for the detection of myocardial inflammation, but comparable for detecting extra-cardiac inflammation.

BACKGROUND We compared the diagnostic accuracy of longitudinal strain (LS) imaging during stress echocardiography with visual assessment of wall motion (WM) for detecting significant coronary artery disease (CAD). METHODS Our systematic search included studies reporting diagnostic measures for LS imaging and visual assessment of WM for detecting significant CAD during stress echocardiography. Summary diagnostic accuracy measures including area under the curve (AUC), sensitivity, specificity, diagnostic odds ratio (DOR), and likelihood ratios (LRs) were estimated. RESULTS In thirteen studies with 978 patients, ten studies used invasive coronary angiography as the reference standard. Pooled AUC for diagnosing significant CAD was 0.92 (95% confidence interval [CI] 0.89-0.94) for LS imaging as compared to 0.83 (95% CI 0.80-0.86), P < 0.001 for visual assessment of WM. LS imaging had higher sensitivity (88% [95% CI 84-92] vs 74% [95% CI 68-80], P < 0.001) and comparable specificity to visual assessment of WM (80% [95% CI 72-87] vs 83% [95% CI 74-90], P = 0.592). The DOR for LS imaging and visual assessment of WM was 31 and 15, P = 0.254, respectively. The positive LR was 4.5 for both; negative LR was 0.14 and 0.31, P = 0.002 for LS imaging and visual assessment of WM, respectively. CONCLUSIONS Longitudinal strain imaging during stress echocardiography has better diagnostic accuracy for detecting significant CAD as compared to visual assessment of WM. Studies using larger sample size and standardized techniques of strain measurement are required to further ascertain the added advantage of strain measurement over visual assessment alone.

Background Cardiovascular disease is a major cause of mortality in patients with nonalcoholic fatty liver disease (NAFLD). However, the association of NAFLD with coronary microvascular dysfunction is, to our knowledge, unknown. Purpose To determine whether coronary microvascular dysfunction is more prevalent in patients with NAFLD and to determine whether coronary microvascular dysfunction predicts major adverse cardiac events (MACE) independently of NAFLD. Materials and Methods This retrospective study (2006-2014) included patients without evidence of obstructive epicardial coronary artery disease and healthy left ventricular ejection fraction (≥40%) at a clinical rest and stress myocardial perfusion PET/CT. NAFLD was defined by a mean hepatic attenuation of less than 40 HU at CT and coronary microvascular dysfunction as a coronary flow reserve (CFR) of less than 2.0. A composite of all-cause mortality, myocardial infarction, coronary revascularization, and hospitalization because of heart failure comprised MACE (130 of 886 patients; 14.7%). The relation between NAFLD and MACE was assessed by using multivariable Cox regression analysis. Results Among 886 patients (mean age, 62 years ± 12 [standard deviation]; 631 women [mean age, 62 years ± 12 years] and 255 men [mean age, 61 years ± 12]; and ejection fraction, 63% ± 9), 125 patients (14.1%) had NAFLD and 411 patients (46.4%) had coronary microvascular dysfunction. Coronary microvascular dysfunction was more prevalent (64.8% vs 43.4%; P < .001) and CFR was lower (1.9 ± 1.1 vs 2.2 ± 0.7; P < .001) in patients with NAFLD compared with those without NAFLD. NAFLD independently predicted coronary microvascular dysfunction (P = .01). The interaction of NAFLD and male sex predicted MACE (hazard ratio, 1.45; 95% confidence interval: 1.08, 1.69; P = .008) and coronary microvascular dysfunction remained associated with MACE (adjusted hazard ratio, 1.46; 95% confidence interval: 1.02, 2.07; P = .04). Conclusion Coronary microvascular dysfunction was more prevalent in patients with nonalcoholic fatty liver disease and predicted major adverse cardiac events independently of nonalcoholic fatty liver disease. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Ambale-Venkatesh and Lima in this issue.

Introduction: The interplay between sleep duration and inflammation on the baseline and incident cardiovascular (CV) risk is unknown. We sought to evaluate the association between sleep duration, C-reactive protein (CRP), baseline CV risk, and incident CV mortality. Methods: We used data from the National Health and Nutrition Examination Survey 2005–2010 linked with the cause of death data from the National Center for Health Statistics for adults aged ≥18 years. The associations between self-reported sleep duration and CRP, 10-year atherosclerotic CV disease risk score (ASCVD) and CV mortality were assessed using Linear, Poisson and Cox proportional hazard modeling as appropriate. Results: There were 17,635 eligible participants with a median age of 46 years (interquartile range [IQR] 31, 63). Among them, 51.3% were women and 46.9% were non-Hispanic Whites. Over a median follow-up of 7.5 years (IQR 6.0, 9.1), 350 CV deaths occurred at an incident rate of 2.7 per 1000-person years (IQR 2.4, 3.0). We observed a U–shaped associations between sleep duration and incident CV mortality rate (P-trend=0.011), sleep duration and 10-year ASCVD risk (P-trend 7 hours of sleep had higher risk of CV death attributable to inflammation after accounting for confounders. Conclusions: There was a U-shaped relationship of incident CV mortality, 10-year ASCVD risk, and CRP with sleep duration. These findings suggest an interplay between sleep duration, inflammation, and CV risk.

Background: Myocardial blood flow (MBF) can be quantified using dynamic PET studies. These studies also inherently contain tomographic images of early bolus displacement, which can provide cardiopulmonary transit times (CPTT) as measure of cardiopulmonary physiology. The aim of this study was to assess the incremental prognostic value of CPTT in heart transplant (OHT) recipients. Methods: 94 patients (age 56 ± 16 years, 78% male) undergoing dynamic 13N-ammonia stress/rest studies were included, of which 68 underwent right-heart catherization. A recently validated cardiac allograft vasculopathy (CAV) score based on PET measures of regional perfusion, peak MBF and left-ventricular (LV) ejection fraction (LVEF) was used to identify patients with no, mild or moderate-severe CAV. Time-activity curves of the LV and right ventricular (RV) cavities were obtained and used to calculate the difference between the LV and RV bolus midpoint times, which represents the CPTT and is expressed in heartbeats. Patients were followed for a median of 2.5 years for the occurrence of major adverse cardiac events (MACE), including cardiovascular death, hospitalization for heart failure or acute coronary syndrome, or re-transplantation. Results: CPTT was significantly correlated with cardiac filling pressures (r =.434, P =.0002 and r =.439, P =.0002 for right atrial and pulmonary wedge pressure), cardiac output (r = − .315, P =.01) and LVEF (r = − .513, P

Introduction: In 2017, the American Heart Association (AHA)/ American College of Cardiology (ACC) revised guidelines for diagnosis of hypertension. The differential impact on prevalence of hypertension among women across high- (United States) and middle-income countries (India) is not known. Hypothesis: There are regional differences in the change in prevalence of hypertension with the new 2017 ACC/AHA guidelines among women. Methods: We used data from National Family Health Survey (NFHS)-4, and the National Health and Nutrition Examination Survey (NHANES) 2015-16 to estimate prevalence of hypertension among non-pregnant women aged 18-49 years in India and the United States, respectively. Both surveys are conducted by respective federal governments to estimate national health status. Hypertension was defined as an average systolic BP (SBP) ≥130 or diastolic BP (DBP) ≥90 mmHg or on treatment in new and SBP/DBP ≥140/≥90 mmHg or on treatment in JNC-7 (old) guidelines. The Chi-Square test was used to compare the association between categorical variables. Results: There were 565,813 and 1,607 eligible participants in NFHS-4 (India) and NHANES (the United States), respectively. Mean age was comparable (31.9±9.0 vs. 33.5±9.4 years, p(Figure Panel A) . The new guidelines flipped the prevalence of hypertension such that it was significantly higher among women in India as compared to US overall and across all age groups (p(Figure Panel B) . Conclusions: There is a higher impact of new guidelines on the prevalence of hypertension among women in India, across all age groups as compared to the United States. Future studies will help understand the mechanisms, risk factors and impact of this change on treatment and health economics in India.

Introduction: Inflammation is associated with worse cardiovascular (CV) prognosis. We evaluated the impact of adding elevated monocyte lymphocyte ratio (MLR) to 10-year atherosclerotic CV disease (ASCVD) risk score. Hypothesis: Adding elevated MLR improves risk classification by 10-year ASCVD risk score. Methods: We used data from 6 cycles of NHANES (1999-2010) to identify ambulatory US adults aged ≥ 18 years without prevalent cardiovascular disease and total leukocyte count in normal range (4,000-11,000 cells/μL). Elevated MLR (≥0.3) was defined using optimal cutoff to predict CV mortality by Youden index. CV mortality was derived from linked National Center for Health Statistics data. We compared the change in reclassification of the 10-year ASCVD risk score at a pre-specified cutoff of 5% (low risk) and reported the net reclassification index (NRI). We further compared predictive value of the circulating immune with risk factors in ASCVD risk score using time-to-event and logistic models. Results: Among 21,599 eligible participants with median age 47 years (IQR, 34, 63; 49.2% women and 49.5% non-Hispanic White), there were 627 CV deaths with annual incidence rate of 0.3% over median follow-up of 9.6 years (IQR 6.8, 13.1). Median ASCVD risk score was 5% (IQR 1.6, 16.7). Adding elevated MLR to categorical 10-year ASCVD risk score correctly up classified 3.2% participants with CV mortality and incorrectly up classified 0.4% participants with no CV mortality. There was significant improvement in risk classification (NRI 2.7±1.4%, p=0.044, Panel A). Adding elevated CRP (≥0.3 mg/dL) did not change risk class (NRI -0.2±0.0%, p=827, Panel B). Among ASCVD components, MLR had higher predictive value than race, smoking, high-density lipoprotein, and total cholesterol in both time-to-event and logistic models. Conclusions: Elevated MLR significantly improves CV risk reclassification in ambulatory adults without prevalent CV disease and is better than CRP.

Introduction: Sleep disturbance is associated with higher inflammation and cardiovascular mortality. The interplay between sleep duration and inflammation as an effect modifier for cardiovascular risk is unknown. Hypothesis: We sought to evaluate the association between sleep duration, C-reactive protein (CRP), and cardiovascular mortality. Methods: We used data from the National Health and Nutrition Examination Survey (NHANES) 2005-2010 linked with the cause of death data from the National Center for Health Statistics for adults aged ≥18 years. The associations between short (9 hours) sleep duration with inflammation (CRP) and cardiovascular mortality were explored using linear, Poisson and Cox proportional hazard modeling. Results: There were 17,635 eligible participants. The mean age was 47.5±19.2 years with 51% women and 47% self-identified non-Hispanic Whites. There were 2,755 (15.6%), 14,340 (81.3%), and 540 (3.1%) participants in the short, adequate, and long sleep duration groups, respectively. There were 60 (2.2%), 268 (1.9%), and 22 (4.1%) cardiovascular deaths in the short, adequate, and long sleep duration groups, respectively. The adjusted hazard of cardiovascular mortality was 24% (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.05-1.47, p=0.012) and 78% (HR 1.78, 95% CI 1.37, 2.30, p Conclusions: Short and long sleep duration are independently associated with a higher hazard of cardiovascular mortality and CRP. These findings suggest an association between circadian rhythm, mortality, and inflammation.

Background: Assessment of heterogeneity in meta-analyses is critical to ensure the consistency of pooled results. Therefore, we sought to assess the evaluation and reporting of heterogeneity in heart failure (HF) meta-analyses. Methods: Study level meta-analyses pertaining to HF were selected from January 2009 to July 2019, published in 11 high impact factor journals. We tabulated the overall proportion of the meta-analyses reporting statistical heterogeneity and specific metrics and methods employed to quantify and explore heterogeneity. Results: Of 126 HF meta-analyses (612 outcomes), heterogeneity was reported for 422 outcomes (68.9 %) in 108 meta-analyses. Out of the 422 outcomes reporting statistical heterogeneity, 137 outcomes (32.5%) had no observable heterogeneity: ( I 2 =0%), 40 outcomes (9.5%) had low heterogeneity ( I 2 I 2 =25%–50%), and 169 outcomes (40%) had high heterogeneity ( I 2 >50%). Reporting of statistical heterogeneity was not significantly associated with year of publication, funding source, disclosure information, or the type of studies pooled. Sensitivity analysis (n=68) was the most common statistical technique employed to evaluate the source of heterogeneity followed by subgroup analyses (n=59) and meta-regression (n=40). Conclusions: Despite being an essential component of meta-analyses, heterogeneity was not reported for nearly 30% of outcomes and variably handled in contemporary HF meta-analyses. As meta-analyses increase across HF science, interpreting and handling of heterogeneity should be standardized.

Objective To investigate the relative predictive value of circulating immune cell markers for cardiovascular mortality in ambulatory adults without cardiovascular disease. Methods We analyzed data of participants enrolled in the National Health and Nutrition Examination Survey from January 1, 1999, to December 31, 2010, with the total leukocyte count within a normal range (4000-11,000 cells/μL [to convert to cells ×109/L, multiply by 0.001]) and without cardiovascular disease. The relative predictive value of circulating immune cell markers measured at enrollment—including total leukocyte count, absolute neutrophil count, absolute lymphocyte count, absolute monocyte count, monocyte-lymphocyte ratio (MLR), neutrophil-lymphocyte ratio, and C-reactive protein—for cardiovascular mortality was evaluated. The marker with the best predictive value was added to the 10-year atherosclerotic cardiovascular disease (ASCVD) risk score to estimate net risk reclassification indices for 10-year cardiovascular mortality. Results Among 21,599 participants eligible for this analysis, the median age was 47 years (interquartile range, 34-63 years); 10,651 (49.2%) participants were women, and 10,713 (49.5%) were self-reported non-Hispanic white. During a median follow-up of 9.6 years (interquartile range, 6.8-13.1 years), there were 627 cardiovascular deaths. MLR had the best predictive value for cardiovascular mortality. The addition of elevated MLR (≥0.3) to the 10-year ASCVD risk score improved the classification by 2.7%±1.4% (P=.04). Elevated MLR had better predictive value than C-reactive protein and several components of the 10-year ASCVD risk score. Conclusion Among ambulatory US adults without preexisting cardiovascular disease, we found that MLR had the best predictive value for cardiovascular mortality among circulating immune markers. The addition of MLR to the 10-year risk score significantly improved the risk classification of participants.

Introduction: While inflammation is associated with worse cardiovascular (CV) prognosis, the relative prognostic importance of circulating immune cell populations for predicting CV mortality is unknown. Methods: We used data from 3 cycles of NHANES (1999-2000, 2001-2002, 2003-2004) to estimate the prognostic importance of total leukocyte count (TLC), and differential leukocyte counts in participants ≥20 years of age and TLC in normal clinical range (4,000-11,000 cells/μL). The cause of death was derived from the National Death Index. We estimated the relative importance of different immune cell markers, and compared the prognostic importance of the dominant immune cell marker with components of the Framingham Risk Score (FRS). We used partial χ2 and standardized domination statistic to estimate the relative importance of immune markers in predicting CV mortality. Results: Among 10, 825 participants (49% women, 51% self-reported Non-Hispanic White) eligible for this analysis, the median age was 49 years (Interquartile Range [IQR] 35 to 66). Over a median follow-up of 13.2 years (IQR 11.4 to 14.8), there were 620 deaths due to CV causes. The hazard of CV mortality increased by 11% with every 1000 cells/uL increase in TLC after adjusting for co-morbidities (Hazard Ratio [HR] 1.11 95% CI 1.02, 1.21, p=0.011). Among the immune cell markers assessed, the monocyte-lymphocyte ratio had the highest domination to predict CV mortality ( Figure Panel A ). The hazard of CV mortality increased by 14% with every 1 unit increase in the monocyte-lymphocyte ratio in the fully adjusted model (HR 1.14 95% CI 1.07, 1.22, pFigure Panel B ). Conclusion: In this study of a large representative adult US population with TLC within the clinically normal range, we found that readily available circulating immune markers are independently associated with CV mortality. The monocyte-lymphocyte ratio was the best predictor of CV mortality and outperformed 5 risk factors included in the FRS.

Aims Hypertension is a well-established heart failure (HF) risk factor, especially in the context of adverse left ventricular (LV) remodelling. We aimed to use myocardial flow reserve (MFR) and global longitudinal strain (GLS), markers of subclinical microvascular and myocardial dysfunction, to refine hypertensive HF risk assessment. Methods and results Consecutive patients undergoing symptom-prompted stress cardiac positron emission tomography (PET)-computed tomography and transthoracic echocardiogram within 90 days without reduced left ventricular ejection fraction ( Conclusion We have demonstrated important associations between coronary microvascular dysfunction and myocardial mechanics that refine disease characterization and HF risk assessment of patients with hypertension based on subclinical target organ injury.

Patients with heart failure with preserved ejection fraction (HFpEF) have a significantly elevated risk of sudden cardiac death (SCD). However, few imaging data have been correlated to this risk. We evaluated the value of multiple echocardiographic markers of left ventricular (LV) function to predict SCD in HFpEF patients. The Treatment of Heart Failure with Preserved Ejection Fraction with Aldosterone Trial (TOPCAT)-Americas cohort was used to evaluate the echocardiographic predictors of SCD and/or aborted cardiac arrest (SCD/ACA). A retrospective cohort design was used. Cox proportional hazards and Poisson regression models were used to determine the associations between the risk of SCD/ACA and echocardiographic parameters: diastolic dysfunction grade, left ventricle ejection fraction, and LV global longitudinal strain (GLS) during follow-up. Impaired left ventricle ejection fraction and GLS were associated with SCD/ACA in univariate models (p = 0.007 and 0.002, respectively), but not diastolic function grade. After multivariate adjustment, only GLS remained a significant predictor of the incidence rate of SCD/ACA (p = 0.006). There was a 58% increase in the hazard of incident SCD/ACA for every 1 unit increase in GLS (1.58, 95%CI: 1.12 to 2.22, p = 0.009). These findings remained robust in the competing risk analyses. In conclusion, amongst the multiple echocardiographic parameters of LV function, GLS may help prognosticate the risk of SCD/ACA in HFpEF patients.

In this post-hoc analysis of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial, we evaluated the prognostic role of anemia in adverse cardiovascular (CV) outcomes in heart failure with a preserved ejection fraction (HFpEF). We defined anemia as hemoglobin of 0.05) as compared to those without anemia. Among CV causes, patients with anemia had a higher risk of sudden cardiac death (SCD)/ACA and presumed CV death (HR 1.67 and 1.83, respectively, p0.05). Among non-CV causes, patients with anemia had a higher risk of death due to malignancy (HR 2.61, p

Importance Impaired myocardial flow reserve (MFR) and stress myocardial blood flow (MBF) on positron emission tomography (PET) myocardial perfusion imaging may identify adverse myocardial characteristics, including myocardial stress and injury in aortic stenosis (AS). Objective To investigate whether MFR and stress MBF are associated with LV structure and function derangements, and whether these parameters improve after aortic valve replacement (AVR). Design, setting, and participants In this single-center prospective observational study in Boston, Massachusetts, from 2018 to 2020, patients with predominantly moderate to severe AS underwent ammonia N13 PET myocardial perfusion imaging for myocardial blood flow (MBF) quantification, resting transthoracic echocardiography (TTE) for assessment of myocardial structure and function, and measurement of circulating biomarkers for myocardial injury and wall stress. Evaluation of health status and functional capacity was also performed. A subset of patients underwent repeated assessment 6 months after AVR. A control group included patients without AS matched for age, sex, and summed stress score who underwent symptom-prompted ammonia N13 PET and TTE within 90 days. Exposures MBF and MFR quantified on ammonia N13 PET myocardial perfusion imaging. Main outcomes and measures LV structure and function parameters, including echocardiographic global longitudinal strain (GLS), circulating high-sensitivity troponin T (hs-cTnT), N-terminal pro-B-type natriuretic peptide (NT-pro BNP), health status, and functional capacity. Results There were 34 patients with AS (1 mild, 9 moderate, and 24 severe) and 34 matched control individuals. MFR was independently associated with GLS and LV ejection fraction, (β,-0.31; P = .03; β, 0.41; P = .002, respectively). Stress MBF was associated with hs-cTnT (unadjusted β, -0.48; P = .005) and log NT-pro BNP (unadjusted β, -0.37; P = .045). The combination of low stress MBF and high hs-cTnT was associated with higher interventricular septal thickness in diastole, relative wall thickness, and worse GLS compared with high stress MBF and low hs-cTnT (12.4 mm vs 10.0 mm; P = .008; 0.62 vs 0.46; P = .02; and -13.47 vs -17.11; P = .006, respectively). In 9 patients studied 6 months after AVR, mean (SD) MFR improved from 1.73 (0.57) to 2.11 (0.50) (P = .008). Conclusions and relevance In this study, in AS, MFR and stress MBF were associated with adverse myocardial characteristics, including markers of myocardial injury and wall stress, suggesting that MFR may be an early sensitive marker for myocardial decompensation.

BACKGROUND: Coronary chronic total occlusion (CTO) using percutaneous coronary intervention (PCI) presents a distinct challenge in the field of cardiology owing to multiple reasons including the increased risk of peri-procedural complications. We sought to explore rates of hospitalization, outcomes, use of mechanical circulatory support devices, and economic burden associated with single-vessel coronary CTO undergoing PCI for stable coronary artery disease (CAD). METHODS: The National Inpatient Sample spanning from 2008 through 2014 was queried to identify hospitalizations associated with single-vessel coronary CTO-PCI for stable CAD by excluding hospitalizations with ST-elevation and non-ST elevation myocardial infarction. Survey-Specific logistic regression was used to analyze adjusted incidence of in-hospital mortality and acute renal failure. RESULTS: A total of 109,094 hospitalizations were identified as having single-vessel coronary CTO-PCI for stable CAD from 2008–2014. An increasing number of coronary CTO-PCI hospitalizations (2,465 to 2,688 per 100,000 PCI procedures, P(trend)

Background: Eighty percent of premature mortality from cardiovascular disease occurs in low- and middle-income countries. Hypertension, diabetes, and smoking are the top risk factors causing this disease burden. Objectives: The study aimed to test the hypothesis that utilizing community health workers (CHWs) to manage hypertension, diabetes and smoking in an integrated manner would lead to improved control of these conditions. Methods: This was a 2-year cluster (n = 12) randomized controlled trial of 3,556 adults (35 to 70 years of age) in a single town in India, who were screened at home for hypertension, diabetes, and smoking. Of these adults, 1,242 (35%) had at least 1 risk factor (hypertension = 650, diabetes = 317, smoking = 500) and were enrolled in the study. The intervention group had behavioral change communication through regular home visits from community health workers. The control group received usual care in the community. The primary outcomes were changes in systolic blood pressure, fasting blood glucose, and average number of cigarettes/bidis smoked daily among individuals with respective risk factors. Results: The mean ± SD change in systolic blood pressure at 2 years was –12.2 ± 19.5 mm Hg in the intervention group as compared with –6.4 ± 26.1 mm Hg in the control group, resulting in an adjusted difference of –8.9 mm Hg (95% confidence interval [CI]: –3.5 to –14.4 mm Hg; p = 0.001). The change in fasting blood glucose was –43.0 ± 83.5 mg/dl in the intervention group and –16.3 ± 77.2 mg/dl in the control group, leading to an adjusted difference of –21.3 mg/dl (95% CI: 18.4 to –61 mg/dl; p = 0.29). The change in mean number of cigarettes/bidis smoked was nonsignificant at +0.2 cigarettes/bidis (95% CI: 5.6 to –5.2 cigarettes/bidis; p = 0.93). Conclusions: A population-based strategy of integrated risk factor management through community health workers led to improved systolic blood pressure in hypertension, an inconclusive effect on fasting blood glucose in diabetes, and no demonstrable effect on smoking. (Study of a Community-Based Approach to Control Cardiovascular Risk Factors in India [SEHAT]; NCT02115711). Highlights Previous studies have used community health workers (CHWs) to target single cardiovascular risk factors. We conducted a randomized controlled trial to test an integrated approach to hypertension, diabetes, and smoking through CHWs. We found that CHWs have a significant effect on hypertension, an inconclusive effect on diabetes, and no effect on smoking. Low- and middle-income countries such as India should consider home-based care for cardiovascular risk factors through CHWs.

Objectives The purpose of this study was to compare trends of use, in-hospital mortality, and annual expenditures associated with orthotopic heart transplantation (OHT) and left ventricular assist device (LVAD) implantation. In view of the changing health care landscape, we assessed the impact of federal funding cuts on Medicare and Medicaid beneficiaries seeking these procedures. Background Use and cost trends associated with OHT and LVAD are not well defined. Moreover, little is known about the economic contribution of Medicare and Medicaid for these procedures. Methods Using the National Inpatient Sample from 2009 through 2014, the study identified index hospitalizations for OHT and LVAD. The aforementioned trends and inflation-adjusted cost analyses were performed. Results A total of 28,765 hospitalizations associated with OHT or LVAD were identified. The number of index hospitalizations for OHT increased from 1,795 to 2,140, whereas the number of LVAD implants increased from 2,205 to 3,645 (ptrend Conclusions With increasing use and annual expenditure, OHT and LVAD account for more than 1 billion dollars of the health care budget. In-hospital mortality associated with LVAD has continued to decline but has remained higher than that with OHT. Medicare and Medicaid beneficiaries seeking these procedures would be adversely affected by the proposed cuts.