Arterial stiffness assessment in coronary microvascular dysfunction and heart failure with preserved ejection fraction: An initial report from the WISE-CVD continuation study

Background

Heart failure with preserved ejection fraction (HFpEF) is the most common cardiac complication in patients with coronary microvascular dysfunction (CMD), yet its underlying pathways remain unclear. Aortic pulse-wave velocity (aPWV) is an indicator of large artery stiffness and a predictor for cardiovascular disease. However, aPWV in CMD and HFpEF is not well characterized and may provide understanding of disease progression.

Methods

Among participants without obstructive coronary artery disease, we evaluated 51 women with suspected CMD and 20 women and men with evidence of HFpEF. All participants underwent aPWV measurement (SphygmoCor, Atcor Medical) with higher aPWV indicating greater vascular stiffness. Cardiac magnetic resonance imaging (CMRI) assessed left ventricular (LV) ejection fraction, CMD via myocardial perfusion reserve index (MPRI), and ventricular remodeling via LV mass-volume ratio. . Statistical analysis was performed using Wilcoxon rank sum tests, Pearson correlations and linear regression analysis.

Results

Compared to the suspected CMD group, the HFpEF participants were older (65 ± 12 vs 56 ± 11 yrs., p = 0.002) had higher BMI (31.0 ± 4.3 vs 27.8 ± 6.7 kg/m2, p = 0.013), higher aPWV (10.5 ± 2.0 vs 8.0 ± 1.6 m/s, p = 0.05) and lower MPRI (1.5 ± 0.3 vs1.8 ± 0.3, p = 0.02), but not remodeling. In a model adjusted for cardiovascular risk factors, the HFpEF group had a lower LVEF (estimate -4.78, p = 0.0437) than the suspected CMD group.

Conclusions

HFpEF participants exhibit greater arterial stiffness and lower myocardial perfusion reserve, with lower LVEF albeit not remodeling, compared to suspected CMD participants. These findings suggest arterial stiffness may contribute to progression from CMD to HFpEF. Prospective work is needed and ongoing.

Cardiometabolic health after first pregnancy: Associations with social determinants of health. A nuMoM2b-HHS study

Study objective

This study sought to evaluate the associations between social determinants of health (SDOH) at the time of first pregnancy and subsequent cardiometabolic health, defined as the development of metabolic syndrome.

Design

nuMoM2b-HHS (Nulliparous Pregnancy Outcomes Study- Monitoring Mothers-to-Be-Heart Health Study) is an ongoing prospective cohort study.

Setting

Eight academic medical centers enrolled and continue to follow participants.

Participants

4484 participants followed a mean of 3.2 years from the time of their first pregnancy.

Interventions

N/a.

Main outcome measure

Unadjusted and adjusted Poisson regression models with robust standard errors were used to obtain relative risks and 95% confidence intervals estimating the risk of metabolic syndrome for each baseline SDOH. In secondary analyses we examined the associations between SDOH and incident hypertension, obesity, and diabetes mellitus.

Results

Metabolic syndrome developed in 13.6% of participants. Higher socioeconomic position at the time of pregnancy was associated with lower rates of metabolic syndrome [income > 200% poverty level aRR 0.55 (95% CI, 0.42-0.71), attainment of a bachelor's degree aRR 0.62 (0.46-0.84) or higher aRR 0.50 (0.35-0.71)], while being single [aRR 1.45 (95% CI, 1.18-1.77)] and having low health literacy were associated with a greater risk of metabolic syndrome [aRR 1.98 (95% CI, 1.28-3.07)].

Conclusions

Over a short interval following first pregnancy, participants accumulated high proportions of cardiovascular risk factors and metabolic syndrome, with some risk associated with SDOH. The impact of interventions addressing SDOH in pregnant people on cardiometabolic health should be tested as a means of reducing health inequities at the population level.

Coronary atheroma burden predicts flow reserve in women with ischemia and nonobstructive coronary artery disease

Background

Women with signs and symptoms of ischemia and no obstructive coronary artery disease often have coronary microvascular dysfunction (CMD) with reduced coronary flow reserve (CFR), and compensatory coronary remodeling. Angiographic measurements of epicardial coronary anatomy (AMCA) may improve understanding of relations between CFR and atherosclerosis. We investigated AMCA and CFR in women evaluated for CMD.

Methods

Women consecutively enrolled in the Women's Ischemia Syndrome Evaluation CVD Continuation (NCT00832702) were included. All underwent clinically indicated coronary function testing measuring CFR. AMCA included coronary angiographic atheroma burden (AB), percent diameter stenosis (PDS), and tapering reference diameter Z score (RDZ), derived for the left main and left anterior descending coronary epicardial segments.

Results

The 51 women were aged 55.8 ± 10.8 years, with 19(38%) hypertensive, 10(20.4%) hyperlipidemic, 4(7.8%) diabetic, 13(25.5%) prior smokers, and mean CFR 3.0 ± 0.8. Both average and maximal AB negatively correlated with CFR (r = -0.30 and -0.31, with p = 0.04 for both), as did average and maximal PDS (r = -0.38 and -0.41 with p = 0.009 and p = 0.005) while average RDZ was directly related (r = 0.37, p = 0.01). Multiple linear regression analyses revealed that both average PDS (Units of CFR -0.03 95% CI: -0.06, -0.002, p = 0.023) and maximal PDS (-0.04 95% CI -0.07, -0.01, p = 0.007) were negatively related to CFR.

Conclusions

Measures of epicardial coronary atheroma burden, size and tapering are related to CFR, suggesting that atherosclerotic anatomical findings may contribute to or be a consequence of CMD, with further work is needed to investigate these measures as treatment targets.

Electrocardiographic (ECG) predictors of major adverse cardiac events in women with ischemia and no obstructive coronary artery disease (INOCA)

Introduction

The Women's Ischemia Syndrome Evaluation (WISE) studies observed that majority of women undergoing coronary angiography for symptoms/signs of ischemia have no obstructive coronary artery disease (INOCA) but have an increased risk of major adverse cardiac events (MACE) exceeding 2.5% yearly by 5 years. Identifying modifiable and non-modifiable factors that help predict or contribute to adverse outcomes in this population is important.

Purpose

Identifying electrocardiographic predictors of MACE in women with INOCA.

Methods

In a cohort of women referred for coronary angiography between 1996–2001 for symptoms and/or signs of ischemia, 944 underwent a resting 12-lead ECG at baseline read at core lab. No obstructive CAD was found in 567/944 (60%), (mean age 55.6±11 years). Complete follow up information for MACE as (first occurrence of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, or hospitalization for heart failure) or angina was available in 425 women.

Results

At follow up (median 5.9 years) MACE had occurred in 17.6% with angina hospitalization in 22.8% of these women. Women who experienced MACE were older (mean age 59±11 vs 55±10 years, P=0.02) and had longer corrected QT interval (mean QTc 437±29.7 vs 425±26.7 ms, P=0.001) vs. women without MACE. Diabetes, hypertension and history of smoking did not differ between MACE groups. Predictors of MACE by univariate analysis were: age at presentation (P=0.013), baseline heart rate (P=0.03), and QTc (P=0.0005). Baseline ST-T wave changes, QTc and waist circumference predicted angina hospitalization (P=0.003, 0.003 and 0.013 respectively). After adjusting for other risk factors in the multivariate analysis (see Figure) QTc, peripheral arterial disease (PAD) and current smoking were found to be independent predictors for MACE. ST-T wave changes and QTc independently predicted angina hospitalizations.

Conclusion

Among ECG findings in women with INOCA, QTc was a significant predictor of MACE and this was driven by hospitalization with angina. Ongoing ischemia likely contributes to these baseline ECG signals which could prove useful to better select subgroups for more intense anti-ischemic management.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Heart, Lung, and Blood Institute (NHLBI)

Role of physical fitness in the obesity paradox. Long-term major adverse cardiovascular events in the Women's Ischemia Syndrome Evaluation (WISE)

Background

Emerging data suggests there is an “obesity paradox” where obesity may be protective against cardiovascular morbidity and mortality in patients with cardiovascular disease. However, weight status primarily assessed through body mass index (BMI) is limited in its ability to discern contributions from fat vs. lean muscle mass. Most studies on BMI have not accounted for physical fitness, which is a known modifier of weight status and a potential mediator of effects of obesity on major adverse cardiovascular events (MACE).

Purpose

To investigate the relationship between BMI and physical fitness, measured by self-reported Duke Activity Status Index (DASI) score, with long-term MACE in women evaluated for suspected myocardial ischemia.

Methods

The National Heart, Lung, and Blood Institute Women's Ischemia Syndrome Evaluation (WISE) study is a multicenter prospective cohort study. From 1996–2000, 936 women were enrolled at the time of clinically indicated coronary angiography and assessed with a median follow up of 5.8 (range 0–9 years) for MACE. MACE was defined as a composite of death, nonfatal myocardial infarction, stroke, or congestive heart failure. Proportional hazards regression was used to estimate adjusted hazard ratios of MACE in relation to metabolic status and physical fitness. DASI scores ≥25, equivalent to ≥7 metabolic equivalents [METs]) was used as cut point to define high physical fitness, in our prior studies DASI >25 approximates completion of the second stage of a Bruce treadmill protocol.

Results

Among the 899 women with complete data, 69.5% had low physical fitness (DASI scores <25), 34.9% overweight (BMl ≥25 to 30), 40.5% obese (BMI ≥30). In fit women, obesity was associated with lower hazard ratio for MACE (HR 0.64, p=0.01); while low fitness in normal weight women was associated with 60% excess risk of MACE (HR 1.61, p=0.01) (Figure 1).

Conclusions

Among women undergoing coronary angiography for suspected myocardial ischemia, obesity was inversely related with long-term MACE in physically fit women. Our findings suggest that physical fitness may play a role in the obesity paradox. These results support the inclusion of fitness in understanding the relations between body weight and long-term MACE. The DASI is a simple, self reported tool that can identify higher-risk symptomatic women and should be considered in future investigations and routine examination of normal, overweight and obese women.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): U01 HL064829