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.

Sex Disparities in Cardiovascular Disease

Cardiovascular disease is the leading cause of death in women. It remains underdiagnosed, undertreated, and portends worse outcomes in women than men. Disparities exist in every stage of science, from bench research to the editorial board of major journals and in every cardiovascular subspecialty. This review summarizes differences in cardiovascular risk factors and disparities in management and outcomes of ischemic heart disease, heart failure, aortic stenosis, and atrial fibrillation. It also provides an overview of female representation as participants and leaders of clinical trials, editorial boards, and academic institutions. Strategies to overcome these disparities are proposed with examples of successful programs.

Management of a Large Pericardial Effusion in Pregnancy: A Multidisciplinary Approach

Pericardial effusions are rarely brought to clinical attention in pregnancy. When present, effusions are typically small, clinically silent, and related to fluid shifts in pregnancy. We present a case of a large pericardial effusion during the third trimester of pregnancy with management considerations for labor and delivery.

Addressing Structural Racism Through Public Policy Advocacy: A Policy Statement From the American Heart Association

During the COVID-19 pandemic, the American Heart Association created a new 2024 Impact Goal with health equity at its core, in recognition of the increasing health disparities in our country and the overwhelming evidence of the damaging effect of structural racism on cardiovascular and stroke health. Concurrent with the announcement of the new Impact Goal was the release of an American Heart Association presidential advisory on structural racism, recognizing racism as a fundamental driver of health disparities and directing the American Heart Association to advance antiracist strategies regarding science, business operations, leadership, quality improvement, and advocacy. This policy statement builds on the call to action put forth in our presidential advisory, discussing specific opportunities to leverage public policy in promoting overall well-being and rectifying those long-standing structural barriers that impede the progress that we need and seek for the health of all communities. Although this policy statement discusses difficult aspects of our past, it is meant to provide a forward-looking blueprint that can be embraced by a broad spectrum of stakeholders who share the association's commitment to addressing structural racism and realizing true health equity.

Differences in clinical presentation and outcomes in pregnancy-associated Takotsubo Syndrome- A scoping review of the literature: Outcomes in pregnancy-associated Takotsubo

BACKGROUND

Takotsubo syndrome (TS) during pregnancy and postpartum is rare but may lead to significant maternal and fetal morbidity. We compared clinical characteristics and prognosis according to [a] timing of presentation (pregnancy vs post-partum) and [b] modes of delivery (cesarean section vs vaginal delivery).

METHODS

Systematic review of articles published in PubMed, Scopus, Embase, and Medline databases from inception to July 30, 2023. Patient demographics, obstetric, electrocardiographic, laboratory, echocardiographic characteristics, and prognosis were summarized descriptively.

RESULTS

An initial database search identified 2162 articles, of which 81 studies were included in this review. TS during pregnancy can have emotional, obstetric, and metabolic triggers and has a higher proportion of adverse fetal outcomes when compared with women who developed TS postpartum. Women with TS after cesarean section had an earlier onset and higher proportion of anesthesia use when compared with those who developed TS after vaginal delivery. There were no differences regarding the degree of systolic dysfunction or the need for advanced therapies, including ventilator support, intra-aortic balloon pump, and extracorporeal membrane oxygenation among groups.

CONCLUSIONS

TS is associated with various triggers and adverse fetal outcomes when it develops during pregnancy than in the postpartum period. TS occurs more rapidly and with a more aggressive course after cesarean section than after vaginal delivery.

Locking the Revolving Door: Racial Disparities in Cardiovascular Disease

Racial disparities in cardiovascular disease are unjust, systematic, and preventable. Social determinants are a primary cause of health disparities, and these include factors such as structural and overt racism. Despite a number of efforts implemented over the past several decades, disparities in cardiovascular disease care and outcomes persist, pervading more the outpatient rather than the inpatient setting, thus putting racial and ethnic minority groups at risk for hospital readmissions. In this article, we discuss differences in care and outcomes of racial and ethnic minority groups in both of these settings through a review of registries. Furthermore, we explore potential factors that connote a revolving door phenomenon for those whose adverse outpatient environment puts them at risk for hospital readmissions. Additionally, we review promising strategies, as well as actionable items at the policy, clinical, and educational levels aimed at locking this revolving door.

The Stressed Heart: A Case Report of Takotsubo Cardiomyopathy in a Patient With Known Coronary Artery Disease

Takotsubo cardiomyopathy and acute coronary syndrome are often clinically indistinguishable, making their differentiation challenging for physicians. We present a case of a 65-year-old female who presented with acute chest pain, shortness of breath, and a recent psychosocial stressor. This is a unique case in which our patient, with known history of coronary artery disease and recent percutaneous intervention, favored a misleading initial diagnosis of non-ST elevation myocardial infarction.

Improving Access to Cardiovascular Care Through Telehealth: A Single-Center Experience

Background

Historically, access to healthcare has been a serious shortcoming of our healthcare system. Approximately 14.5% of US adults lack readily available access to health care and this has been worsened by the coronavirus disease 2019 (COVID-19) pandemic. There are limited data on the use of telehealth in cardiology. We share our single-center experience in improving access to care via telehealth at the University of Florida, Jacksonville cardiology fellows' clinic.

Methods

Demographic and social variables were collected 6 months before and 6 months after the initiation of telehealth services. The effect of telehealth was determined via Chi-square and multiple logistic regression while controlling for demographic covariates.

Results

We analyzed 3,316 cardiac clinic appointments over 1 year. Of these, 1,569 and 1,747 were before and after the start of telehealth, respectively. Fifteen percent (272 clinical encounters) out of the 1,747 clinic visits during the post-telehealth era were through telehealth, completed via audio or video consultation. Overall, there was a 7.2 % increase in attendance after the implementation of telehealth (P value < 0.001). Patients who attended their scheduled follow-up had significantly greater odds of being in the post-telehealth group while controlling for marital status and insurance type (odds ratio (OR): 1.31, 95% confidence interval (CI): 1.07 - 1.62). Patients who attended had higher odds of having City-Contract insurance - an institution-specific indigenous care plan (OR: 3.51, 95% CI: 1.79 - 6.87) compared to private insurance. Patients who attended also had higher odds of being previously married (OR: 1.34, 95% CI: 1.05 - 1.70) or married/dating (OR: 1.39, 95% CI: 1.05 - 1.82) compared to patients who were single. Surprisingly, telehealth did not lead to an increase in the use of Mychart, our electronic patient portal (P value = 0.55).

Conclusions

Telehealth enhanced patients' access to care by improving appointment show-rate in a cardiology fellows' clinic during the COVID-19 pandemic. Telehealth as a resource adjunct to traditional care in cardiology fellows' clinic should be further explored.

Late Presentation of Massive Aortic Aneurysm with Aortic Regurgitation

•Clinical manifestations of AR can vary widely. •Echocardiography is critical in diagnosis and surveillance of AR and aortopathy. •Aortic root aneurysm > 5.5 cm and LVEF < 55% increase mortality. •Surgery remains a key treatment option in cases not amenable to medical therapy.

Role of Diabetes Mellitus in Heart Failure With Preserved Ejection Fraction: A Review Article

The pathophysiology of heart failure with preserved ejection fraction (HFpEF) is complex and poorly understood. There is a high prevalence of Diabetes Mellitus (DM) in patients with HFpEF, and the presence of DM has been shown to increase mortality of patients with HFpEF by 30%-50% even after adjustment for age, gender, hospital factors, and other patient characteristics. Since the prevalence of both entities is increasing worldwide, there is a need to explore their intricate relationship in order to elucidate potential management strategies to reduce the morbidity and mortality associated with this duo. In this review article, we explore the role of DM in the pathophysiology of HFpEF, ethnic and gender differences, and some therapeutic strategies in the management of patients with HFpEF and DM.

Right Atrial Appendage Thrombus in Atrial Fibrillation: A Case Report and Review of the Literature

Atrial fibrillation (Afib) is the most common abnormal heart rhythm in adults and has become a significant public health concern affecting 2% to 3% of the population in Europe and North America. Left atrial appendage (LAA) thrombi is the source of 90% of left-sided cardiac thrombi in patients with Afib, which can cause stroke and other systemic vascular events. Right atrial appendage (RAA) thrombi formation in Afib is much less common but complications include pulmonary embolism or paradoxical migration across patent foramen ovale with risk of systemic embolization. The prevalence and subsequent clinical complications of RAA thrombi formation in Afib patients is not well understood. Management of RAA thrombi should be similar to that of LAA thrombi which includes delaying cardioversion and anticoagulating with warfarin therapy to achieve international normalized ratio of 2 to 3.

Heerfordt-Waldenström Syndrome Manifesting as Cardiac Sarcoidosis

Sarcoidosis is a granulomatous disease histologically characterized by non-caseating granulomas. Although it usually affects the lungs, it can affect any organ system and present with a wide variety of symptoms. Heerfordt-Waldenström Syndrome, or uveoparotid fever, is a rare form of sarcoidosis that presents with a combination of fever, parotitis, facial paralysis, and uveitis. In this case report, we demonstrate a rare manifestation of sarcoidosis in a patient who presents with both the aforementioned syndrome and cardiac involvement. This case serves to highlight the importance of identifying the various clinical manifestations and management of systemic sarcoidosis.

Barriers, Opportunities, and Challenges in Addressing Disparities in Diet-Related Cardiovascular Disease in the United States

In the United States, cardiovascular disease (CVD) is the leading cause of death and disability. Suboptimal diet quality is responsible for a greater percentage of CVD-related morbidity and mortality than any other modifiable risk factor. Further troubling are the stark racial/ethnic and socioeconomic disparities in diet quality. This represents a major public health concern that urgently requires a coordinated effort to better characterize the barriers to healthy dietary practices in population groups disproportionally affected by CVD and poor diet quality to inform multifaceted approaches at the government (policy), community environment, sociocultural, and individual levels. This paper reviews the barriers, opportunities, and challenges involved in shifting population behaviors, especially in underserved populations, toward healthy dietary practices. It is imperative that public health policies address the social determinants of nutrition more intensively than previously in order to significantly decrease CVD on a population-wide basis.

Intraparenchymal haemorrhage and uncal herniation resulting from dobutamine stress echocardiography

Intracranial haemorrhage (ICH) resulting from dobutamine stress echocardiography (DSE) is a rare complication in an otherwise relatively safe procedure. There has been one previously reported case of ICH associated with DSE in a patient who was fully anticoagulated. The authors report a second case of ICH associated with DSE leading to a poor outcome. Unlike the previous report, this patient was not fully anticoagulated and bleeding resulted from uncontrolled hypertension. Clinicians should be attentive to the risk of ICH associated with DSE in the setting of uncontrolled hypertension.

Use of the caco-2 model in the screening of polluting substance toxicity

The aim of this work was to investigate the oral toxicity of representative chemicals chosen from each class of the list of 132 substances present in industrial effluents after the EEC Directive 76-464. Owing to its characterization as a model of the intestinal epithelium, the CaCo-2 cell line model was chosen. Cytotoxicity was assayed using the tetrazolium blue (MTT) test. For most of the substances, a linear correlation was observed between the octanol/water partition coefficient (log Kw) and the median inhibition concentration (IC(50)). This relationship between lipophilicity and toxicity is the hallmark of a narcotic mechanism of action. However, diethylamine appeared more toxic than the correlation would predict. Other amines were then tested (tert-butylamine, n-butylamine and benzylamine). All of these did not fit into the baseline correlation. The IC(50) were corrected by taking into account only the non-ionized, lipid insoluble, concentration at pH7.3. The amines still did not fit into the correlation, reinforcing the idea of a non-narcotic mechanism. The toxicity of a large number of substances can thus be predicted from their physico-chemical properties only when the substances exert a direct and non-specific effect. The amines appeared more toxic than substances with the same partition coefficient, showing that knowledge of the only lipophilicity is too restrictive to predict toxicity.

Use of transepithelial electrical resistance in the study of pentachlorophenol toxicity

The toxicity of pentachlorophenol (PCP), a polluting substance believed to exert a narcotic effect, was assayed using the Caco-2 cell line as a model. In order to assess this toxicity as fully as possible, several viability tests, each examining different endpoints, have been used. Neutral red uptake was found to be more sensitive to PCP than MTT and Alamar Blue tests. Transepithelial electrical resistance (TEER) was shown to be the most sensitive to PCP at concentrations and exposure times where the Alamar Blue, LDH leakage and Blue Dextran passage did not evidence any effect. Blue Dextran passage and optical microscopy revealed cellular detachment at concentrations where LDH and Alamar Blue showed little or no cytotoxicity. Thus, PCP seems to affect the integrity of the intestinal barrier at levels where no cytotoxicity is seen. Our results support the notion that TEER can be used as a very sensitive method for evaluating membrane-perturbing toxicants.

Role of hypertension in the metabolic syndrome: who is affected?

Hypertension is one of the components of the metabolic syndrome. The "deadly quartet," as this syndrome is often referred to, also includes atherogenic dyslipidemia; hyperglycemia and/or insulin resistance (IR); and abdominal obesity. More than 47 million people in the United States have the metabolic syndrome, with a higher prevalence in certain ethnic groups. This is expected to rise significantly in the future, in large part due to the obesity epidemic. The relative contribution of each of the constituents of this syndrome varies according to the population in which it occurs, but the significance of these variations is not known. In this article, we review the role of hypertension in the metabolic syndrome, its complex association with obesity and IR, and its disproportionate contribution to the syndrome in certain ethnic groups (specifically US blacks).

Three-dimensional structure of transporter associated with antigen processing (TAP) obtained by single Particle image analysis

The transporter associated with antigen processing (TAP) is an ATP binding cassette transporter responsible for peptide translocation into the lumen of the endoplasmic reticulum for assembly with major histocompatibility complex class I molecules. Immunoaffinity-purified TAP particles comprising TAP1 and TAP2 polypeptides, and TAP2 particles alone were characterized after detergent solubilization and studied by electron microscopy. Projection structures of TAP1+2 particles reveal a molecule approximately 10 nm across with a deeply staining central region, whereas TAP2 molecules are smaller in projection. A three-dimensional structure of TAP reveals it is isolated as a single heterodimeric complex, with the TAP1 and TAP2 subunits combining to create a central 3-nm-diameter pocket on the predicted endoplasmic reticulum-lumenal side. Its structural similarity to other ABC transporters demonstrates a common tertiary structure for this diverse family of membrane proteins.

Bioimpedance monitoring of rehydration in cholera

Measurement of bioimpedance (BI) is a simple non-invasive technique that relies on the different conductivity of tissues to define body composition and can be easily adapted to automated monitoring. We assessed the accuracy of BI in monitoring rehydration and acute fluid fluxes in 35 Peruvian cholera patients. Patients were monitored throughout the acute phase of diarrhoea and followed up at 3 and 10 days. BI was compared with other objective measures of dehydration including packed cell volume, serum protein, and calculated fluid balance. BI rapidly detected inadequate treatment and acute fluid flux, correlating highly with intravascular hydration as measured by serum protein and packed cell volume. BI values during dehydration were significantly raised compared with 10-day convalescent values and age-matched controls (p < 0.05). We also encountered an unexpected difference in the bioelectrical response to dehydration and rehydration between sexes. We conclude that BI has uses in monitoring dehydrated patients, in oral rehydration trials, and in physiological studies.