Total occlusion (TO) of the culprit artery usually presents with ST-elevation myocardial infarction. A subset of patients with TO present as non-ST segment elevation myocardial infarction (NSTEMI) ...without classic ST-elevation on the electrocardiogram. This may lead to delay in identification of these patients and further management. We performed a meta-analysis to estimate the difference in outcomes between totally occluded and non-occluded culprit arteries in patients with NSTEMI.
Our literature search yielded seven studies with 40 777 patients. The outcomes assessed were clinical presentation (Killip class), left ventricular ejection fraction, time to angiography, major cardiac adverse events (MACE) and all-cause mortality. The generic inverse or Mantel-Haenszel method was used to pool relevant outcomes and the mean difference (MD) or relative risk (RR) was calculated. A total of 10 415 (25.5%) patients had an occluded culprit artery with a predominant infero-lateral distribution (40% right coronary and 33% left circumflex artery). There was an increased risk of both MACE (short-term RR: 1.41; CI: 1.17, 1.70; P = 0.0003; I2 = 26%; medium- to long-term RR: 1.32; CI: 1.11, 1.56; P = 0.001; I2 = 25%) and all-cause mortality (short-term RR: 1.67; CI: 1.31, 2.13; P < 0.0001; I2 = 41%; medium to long-term RR: 1.42; CI: 1.08, 1.86; P = 0.01; I2 = 32%) with TO of the culprit artery.
Our meta-analysis suggests that patients with NSTEMI who demonstrate a totally occluded culprit vessel on coronary angiography are at higher risk of mortality and major adverse cardiac events. Better risk stratification tools are needed to identify such high-risk acute coronary syndrome patients to facilitate earlier revascularization and potentially to improve outcomes.
To identify the association between medical or psychiatric comorbidities, clinical characteristics, or course of illness/recovery in pediatric bipolar disorder (BD).
Data from the South Carolina ...Medicaid program covering all medical services and medication prescriptions between January 1996 and December 2005 were used to analyze the temporal onset of 12 comorbid medical or psychiatric conditions for 1,841 children and adolescents diagnosed with BD using DSM-IV-TR criteria and for a random sample of 4,500 children not treated for psychiatric disorders. The primary outcome measures were diagnostic codes and regression analyses of patterns of acute and outpatient treatment services for BD over time.
Ten conditions examined were significantly more prevalent in the BD cohort: obesity, type 2 diabetes mellitus, endocrine disorders, migraine headaches, central nervous system (CNS) disorders/epilepsy, organic brain disorders/mental retardation, cardiovascular disorders, attention-deficit/hyperactivity disorder (ADHD), asthma, and substance abuse (P ≤ .01). For clinical characteristics within the BD cohort, an adolescent-onset diagnosis of BD (age ≥13 years) was significantly associated with the diagnosis of preexisting obesity, hypertension, migraine, mental retardation, endocrine disorders, and substance abuse (P ≤ .05), whereas recurrent depressive episodes were associated with preexisting endocrine disorders and substance abuse. Preexisting ADHD, substance abuse, CNS disorders/epilepsy, cardiovascular disorders, obesity, and asthma were associated with higher overall medical and psychiatric outpatient and acute service use, but none of these comorbid disorders differentially impacted the course of illness or recovery for BD.
Neuropsychiatric (ie, ADHD, substance abuse, CNS disorders/epilepsy) and medical (ie, obesity, asthma, cardiovascular disease) disorders temporally precede the diagnosis of early-onset BD in pediatric patients and are associated with discrete facets of illness presentation, but they do not substantially alter the clinical course of the BD over time.
Cell therapy involves transplantation of human cells to promote repair of diseased or injured tissues and/or cells. Only a limited number of mostly small‐scale trials have studied cell therapy in ...nonischemic cardiomyopathy (NICM). We performed a meta‐analysis of randomized clinical trials (RCTs) to assess the safety and efficacy of cell therapy in NICM. Electronic databases were searched for relevant RCTs from inception until August 2020. Outcomes assessed were left ventricular ejection fraction (LVEF), left ventricular end‐diastolic diameter or volume (LVEDD), quality of life (QoL) indices, and major adverse cardiac events (MACEs). Weighted mean differences (MDs) and standardized mean differences (SMDs) were calculated using random‐effects methods. Eleven RCTs with 574 participants were included in the analysis. There was a significant increase in mean LVEF (MD, 4.17%; 95% confidence interval CI = 1.66‐6.69) and modest decrease in LVEDD (SMD, −0.50; 95% CI = −0.95 to −0.06) in patients treated with cell therapy compared with controls. Cell therapy was also associated with improvement in functional capacity, as assessed by the 6‐minute walking distance (MD, 72.49 m; 95% CI = 3.44‐141.53). No significant differences were seen in MACEs and QoL indices between treated and control groups. This meta‐analysis suggests that cell therapy may improve LV systolic function and may be associated with improvement in LVEDD and functional capacity compared with maximal medical therapy. Cell therapy was safe, with no significant difference in MACEs between treatment and control groups. However, given the limitations of current studies, larger well‐designed RCTs are needed to evaluate the efficacy of cell therapy in patients with NICM.
Among 11 studies included in our systematic review, meta‐analysis of nine studies that reported mean change in left ventricular systolic function from baseline to the end of follow‐up after cell therapy in comparison to control group showed significant increase in left ventricular systolic function over time.
Background: We investigated the treated prevalence of bicuspid aortic valve in a pediatric population with congenital heart disease and its incident complications.
Materials and Methods: A 15-year ...retrospective data set was analyzed. Selection criteria included age ≤17 years, enrollees in the South Carolina State Medicaid program and diagnosed as having bicuspid aortic valve on one or more service visits.
Results: The 15-year-treated prevalence of predominantly isolated bicuspid aortic valve was 2% (20/1000) of pediatric congenital heart disease cases, with a non-African American: African-American ratio of 3.5:1, and a male:female ratio of 1.6:1. Aortic stenosis (28.0%), ventricular septal defect (20.6%), and coarctation of the aorta (20.6%) were the most prevalent coexisting congenital heart lesions. Of the 378 bicuspid aortic valve cases examined, 10.3% received aortic valve repair/replacement, which was significantly more likely to be performed in children with diagnosed aortic stenosis (adjusted odds ratio = 12.90; 95% confidence interval = 5.66-29.44). Cohort outcomes over the study period indicated that 9.5% had diagnosed heart failure, but <1% had diagnosed supraventricular tachycardia, infective endocarditis, aneurysm, dissection, or death.
Conclusions: The majority of isolated bicuspid aortic valve cases without aortic stenosis did not require surgical intervention. Outcomes for cases requiring repair/replacement were relatively benign.
Background Blacks have more severe endothelial dysfunction and aortic stiffening as compared with whites. We aimed to investigate the association between aortic stiffness and microvascular function ...in the black community. Methods and Results We assessed the association between forearm vascular reactive hyperemia (an indicator of microvascular function) and aortic stiffness in 1458 black participants (N=965 66% women; mean age: 66±11 years) in the Jackson Heart Study. We evaluated 2 measures of aortic stiffness: brachial pulse pressure and carotid-femoral pulse wave velocity. Using high-resolution ultrasound and Doppler, we evaluated brachial blood flow at baseline and during reactive hyperemia after 5 minutes of forearm ischemia. Multiple cardiovascular risk factors were significantly related to baseline and hyperemic brachial flow velocity. Women had lower baseline flow across the entire age spectrum. During hyperemia, we observed a significant age-sex interaction for flow velocity ( P=0.02). Female sex was protective against microvascular dysfunction among younger participants, but older women exhibited a greater attenuation of the hyperemic flow reserve. In multivariable models that adjusted for cardiovascular disease risk factors and mean arterial pressure, higher carotid-femoral pulse wave velocity (β=-0.106±0.033; P=0.001 was related to lower baseline flow. However, during reactive hyperemia, elevated brachial pulse pressure (β=-0.070±0.031; P=0.03) and carotid-femoral pulse wave velocity (β=-0.128±0.030; P<0.001) were both related to attenuated brachial flow velocity. Conclusions In a sample of blacks, higher aortic stiffness and pressure pulsatility were associated with lower flow reserve during reactive hyperemia, beyond changes attributable to traditional cardiovascular disease risk factors alone.
Background Black individuals have greater risk for cardiovascular disease ( CVD ) than whites. Identifying CVD risk factors associated with abnormal aortic hemodynamics in blacks may optimize CVD ...prevention and treatment strategies. Methods and Results Jackson Heart Study participants underwent applanation tonometry (2011-2016) with assessment of carotid-femoral pulse wave velocity ( CFPWV ) and forward wave amplitude ( FWA ). CVD risk factors were assessed during examination 3 (2009-2012). We examined the association of risk factors with binary and continuous CFPWV and FWA in multivariable stepwise models. We evaluated for effect modification by sex to determine differential associations of risk factors with aortic hemodynamics in men and women. We examined 1322 individuals (mean age 66±11 years, 66% women). Age was strongly associated with elevated CFPWV (odds ratio, 4.76; 95% confidence interval, 3.84-5.89 P<0.0001) and FWA (odds ratio, 2.30; 95% CI , 1.98-2.69 P<0.0001). Men had greater odds of elevated CFPWV compared with women (odds ratio, 1.54; 95% confidence interval, 1.11-2.13 P=0.009). Heart rate, mean arterial pressure, and use of antihypertensive medications were associated with elevated CFPWV and FWA (all P≤0.02). Additionally, total/high-density lipoprotein cholesterol and fasting glucose were associated with elevated CFPWV (both P≤0.002) and use of diabetes mellitus medications was associated with elevated FWA ( P≤0.0001). We observed a steeper association of age and mean arterial pressure with unfavorable aortic hemodynamics in women than men. Conclusions In blacks in the community, differential CVD risk factors are associated with aortic stiffness and FWA. Future work may determine the impact of risk factor modification on abnormal central aortic hemodynamics and CVD outcomes.
...perhaps most important, the authors' premise that post-graduate training in cardiology at VA sites should replicate that which fellows receive as part of their core training at their respective ...academic health center is somewhat short-sighted. ...the VA learning experience is one that complements and balances the ofttimes more high-volume, procedurally directed inpatient exposure that cardiology fellows receive routinely in their university-based educational experience.
Peripheral vascular endothelial dysfunction assessed by digital peripheral arterial tonometry (PAT) has been associated with risk for adverse cardiovascular events. We examined the relations of ...peripheral microvascular dysfunction and left ventricular mass in a community-based cohort of African Americans. We examined participants of the Jackson Heart Study who had PAT and cardiac magnetic resonance imaging evaluations between 2007 and 2013. Consistent with pertinent literature, left ventricular mass index (LVMI) was adjusted for body size by indexing to height
. Pearson's correlation and general linear regression analyses were used to relate reactive hyperemia index, baseline pulse amplitude (BPA), and augmentation index (markers of microvascular vasodilator function, baseline vascular pulsatility, and relative wave reflection, respectively) to LVMI after adjusting for traditional cardiovascular risk factors. A total of 440 participants (mean age 59 ± 10 years, 60% women) were included. Age- and sex-adjusted Pearson's correlation analysis suggested that natural log transformed LVMI was negatively correlated with reactive hyperemia index (coefficient: -0.114; P = .02) and positively correlated with BPA (coefficient: 0.272; P < .001). In multivariable analyses, higher log
LVMI was associated with higher BPA (β: 0.210; P = .03) after accounting for age, sex, body mass index, diabetes, hypertension, ratio of total cholesterol and high-density lipoprotein cholesterol, smoking, and history of cardiovascular disease. In a community-based sample of African Americans, higher baseline pulsatility measured by PAT was associated with higher LVMI by cardiac magnetic resonance imaging after adjusting for traditional risk factors.
Literature remains scarce on the impact of antiretroviral medications on hypertension in the HIV population. We used the South Carolina Medicaid database linked with the enhanced HIV/AIDS system ...surveillance database for 1994-2011 to evaluate incident hypertension and the impact of combination antiretroviral therapy (cART) in HIV/AIDS population compared with a propensity- matched non-HIV control group. Multivariable, time-dependent survival analysis suggested no significant difference in incidence of hypertension between the HIV group and the non-HIV control group. However, subgroup analysis suggested that among the HIV-infected group, months of exposure to both non-nucleoside reverse transcriptase inhibitors (adjusted hazard ratio, 1.52; 95% confidence interval, 1.3-1.75) and protease inhibitors (adjusted hazard ratio, 1.26; 95% confidence interval, 1.11-1.44) were associated with an increased risk of incident hypertension after adjusting for traditional demographic and metabolic risk factors. In people with HIV/AIDS, prolonged exposure to both protease inhibitor-based and non-nucleoside reverse transcriptase inhibitor-based cART may increase the risk of incident hypertension.
PDF
