Trends in the Prevalence of Infiltrative Cardiomyopathy Among Patients With in-Hospital Cardiac Arrest

Sarcoidosis, amyloidosis, hemochromatosis and scleroderma are the most forms of infiltrative/nonischemic cardiomyopathy (NICM) associated with sudden cardiac death. In patients who undergo in-hospital cardiac arrest, a high index of suspicion is required to rule out NICM as an underlying contributor. We aimed to analyze the prevalence of NICM among patients with in-hospital cardiac arrest and identify factors associated with increased mortality. We analyzed data from the National Inpatient Sample, and identified patients who were hospitalized across 10 years from 2010 to 2019 with a diagnosis of cardiac arrest and NICM. The total number of patients with in-hospital cardiac arrest was 19,34,260. The total number with NICM was 14,803 (0.77%). Mean age was 63 years. Overall prevalence of NICM across the years ranged between 0.75% to 0.9%, with a significant temporal increase (P < 0.01). Incidence of in-hospital mortality ranged between 61% to 76% for females and 30% to 38% for males. The following comorbidities were more prevalent in patients with NICM than those without: heart failure, chronic obstructive pulmonary disease (COPD), chronic kidney disease, anemia, malignancy, coagulopathy, ventricular tachycardia, acute kidney injury and stroke. The following factors were independent predictors of in-hospital mortality-age, female gender, Hispanic race, history of COPD and presence of malignancy (P = 0.042). The prevalence of infiltrative cardiomyopathy in patients with in-hospital cardiac arrest is increasing. Females, older patients and Hispanic population are at an increased risk of mortality. Sex and race-based disparities in the prevalence of NICM in patients with in-hospital cardiac arrest is an area of further research.

Analysis of Left Ventricular Indexes and Mortality Among Asian Adults With Hemodynamically Significant Chronic Aortic Regurgitation

Importance

Chronic hemodynamically significant aortic regurgitation (AR) is associated with excess risk of death, yet data for Asian patients are lacking, and whether Asian patients can abide by Western guidelines as to when aortic valve surgery should be performed is unknown.

Objective

To assess AR presentation and cutoffs of left ventricular ejection fraction (LVEF), LV end-systolic dimension index (LVESDi), and LV end-systolic volume index (LVESVi) that are associated with risk of death in Asian patients with AR.

Design, Setting, and Participants

This retrospective cohort study included consecutive patients with chronic, moderately severe to severe AR from 3 tertiary referral centers (2 in Japan and 1 in Taiwan) from June 11, 2008, through November 19, 2020, with follow-up through November 11, 2021.

Exposures

Aortic regurgitation severity, graded by a comprehensive integrated approach.

Main Outcomes and Measures

The primary outcome was the association between volume-derived LVEF, LVESDi, and LVESVi and all-cause death (ACD). The secondary outcome was the association of these LV indexes with cardiovascular death (CVD). Clinical and echocardiographic data were analyzed retrospectively. A de novo disk-summation method was used to derive LV volumes and volume-derived LVEF.

Results

Of 1259 patients (mean [SD] age, 64 [17] years; 934 [74%] male), 515 (41%) were Japanese and 744 (59%) were Taiwanese. The median follow-up was 4.1 years (IQR, 1.56-7.24 years). The mean (SD) body surface area was 1.67 (0.21) m2; LVEF, 55% (11%); LVESDi, 24.7 (5.7) mm/m2; LVESVi, 50.1 (28.0) mL/m2; and indexed mid-ascending aorta size, 24.7 (5.5) mm/m2. Aortic valve surgery occurred in 483 patients (38%); 240 patients (19%) died during follow-up. Overall mean (SD) 8-year survival was 74% (2%). Separate multivariate models adjusted for covariates demonstrated independent associations of LVEF, LVESDi, and LVESVi with ACD (LVEF: hazard ratio [HR] per 10%, 0.80; 95% CI, 0.70-0.92; P = .002; LVESDi: HR, 1.04; 95% CI, 1.01-1.06; P = .002; LVESVi: HR per 10 mL/m2, 1.11; 95% CI, 1.05-1.17; P < .001) and CVD (LVEF: HR per 10%, 0.69; 95% CI, 0.56-0.85; P < .001; LVESDi: HR, 1.05; 95% CI, 1.01-1.09; P = .01; LVESVi per 10 mL/m2: HR, 1.15; 95% CI, 1.06-1.24; P < .001). In the total cohort, spline curves showed that mortality started to increase for an LVEF of 53% or less, LVESDi of 22 mm/m2 or greater, and LVESVi of 46 mL/m2 or greater for both ACD and CVD. Early surgery was beneficial in 3 strata of LVESDi (<20, 20 to <25, and ≥25 mm/m2) and 2 strata of LVESVi (<46 and ≥46 mL/m2).

Conclusions and Relevance

This multicenter cohort study of Asian patients with hemodynamically significant AR found cutoff values of LVEF, LVESDi, and LVESVi that were associated with increased risk of death. These findings suggest that Western guidelines seem applicable in Asian patients and, most importantly, that indexed LV parameters with a lower cutoff could be used in discriminating patients with excess mortality risk.

Trends in the prevalence of infiltrative cardiomyopathy among patients with in-hospital cardiac arrest – insight from the US national inpatient sample database

Background

Sarcoidosis, amyloidosis, hemochromatosis and scleroderma are the most common systemic disorders leading to infiltrative cardiomyopathy (InCM). Each of them has been associated with conduction abnormalities and sudden cardiac death. In patients who undergo in-hospital cardiac arrest, a high index of suspicion is required to rule out InCM as an underlying contributor.

Purpose

We aimed to analyse the temporal trend in the prevalence of InCM among patients with in-hospital cardiac arrest and identify factors associated with increased mortality in this population.

Methods

We analysed data from the National Inpatient Sample (NIS), which is the largest publicly available database of in-hospital patients in the Unites States. Using ICD-10 coding, we identified patients who were hospitalized across 10 years from 2010–2019. Patients with diagnosis codes for both cardiac arrest and a subtype of InCM were included. Demographic characteristics and co-morbidity data were collected. Statistical analysis was performed using STATA.

Results

The total number of patients with a diagnosis of in-hospital cardiac arrest was 19,34,260. Of these, the total number with InCM was 14,803 (0.77%), which comprised our study population. Mean age was 63 years. The overall prevalence of InCM across the years ranged between 0.75 to 0.9%, with a significant temporal increase (p&lt;0.01). Prevalence of females ranged between 51% to 62% and significantly outnumbered males across the time period. (p=0.011). Incidence of in-hospital mortality ranged between 61% to 76% for females and 30 to 38% for males. Race based analysis showed that prevalence of Caucasians ranged from 51% to 62% while that of African Americans (AA) ranged from 57% to 73%. The incidence of mortality was similar in both populations. Sarcoidosis was the most prevalent form of InCM, accounting for nearly two-fifths of all cases while amyloidosis and scleroderma both accounted for nearly 20% each. Haemochromatosis was present in 10% of the population. Overall mortality rate in our study population was 60.6%. The following co-morbidities were more prevalent in patients with InCM than those without: history of heart failure, chronic obstructive pulmonary disease (COPD), chronic kidney disease, anaemia, malignancy, coagulopathy, ventricular tachycardia, acute kidney injury and stroke. The following factors were independent predictors of in-hospital mortality-age (p=0.001), female gender (p=0.016), Hispanic race (p=0.039), history of COPD (p&lt;0.001) and presence of malignancy (p=0.042).

Conclusion

The prevalence of infiltrative cardiomyopathy in patients with in-hospital cardiac arrest is increasing. Females, older patients and Hispanic population are at an increased risk of mortality. Sex and race based disparities in the prevalence of InCM in patients with in-hospital cardiac arrest is an area of further research.

Funding Acknowledgement

Type of funding sources: None.

Assessment of Cardiac Risk in Women with Autoimmune Disease

PURPOSE OF REVIEW

The purpose of our review was to evaluate current standards in clinical practice in determining overall cardiac risk in female patients with chronic rheumatologic diseases. We hoped to not only summarize known cardiac manifestations of various chronic rheumatologic diseases but also determine the effectiveness of new risk scores in determining cardiac risk in this patient population.

RECENT FINDINGS

Chronic rheumatologic diseases have been associated with various cardiac manifestations for some time, with initial studies involving risk of coronary artery disease (CAD) in rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). However, recent studies have shown numerous other cardiac manifestations associated with these and other chronic rheumatologic diseases. Risk scores have been used for several decades to help determine overall cardiac risk in the general population, but these risk scores have notoriously underestimated the risk of cardiac disease in woman and in patients with chronic rheumatologic diseases. These diseases, often with a female predominance, can impact long-term mortality and have devastating consequences if not monitored and treated appropriately. Thus, new risk scores have been developed over the last several years to help improve detection and awareness of cardiac disease in these patients. Novel modified risk scores have found some success at improving the detection of cardiac disease in patients with chronic rheumatologic diseases. Further studies looking at these risk scores need to determine the accuracy of these scores and where they fall short. With the advent of advanced imaging technologies, future risk scores may involve certain imaging-based markers to help guide accurate risk determination.

Systemic Sclerosis Portends Increased Risk of Conduction and Rhythm Abnormalities at Diagnosis and During Disease Course: A US Population-Based Cohort

Objectives

To study the incidence, risk factors and outcomes of conduction and rhythm disorders in a population-based cohort of patients with systemic sclerosis (SSc) vs. non-SSc comparators.

Methods

An incident cohort of patients with SSc (1980-2016) from Olmsted County, MN was compared to age- and sex-matched non-SSc subjects (1:2). Electrocardiograms (ECGs), Holter ECGs, and need for cardiac interventions were reviewed to determine the occurrence of any conduction or rhythm abnormalities.

Results

78 incident SSc cases and 156 comparators were identified (mean age 56 y, 91% female). The prevalence of any conduction disorder prior to SSc diagnosis compared to non-SSc subjects was 15% vs. 7% (p=0.06), and any rhythm disorder was 18% vs. 13% (p=0.33). During a median follow-up of 10.5 years in patients with SSc and 13.0 years in non-SSc comparators, conduction disorders developed in 25 patients with SSc with cumulative incidence of 20.5% (95% CI: 12.4-34.1%) vs. 28 non-SSc patients with cumulative incidence of 10.4% (95% CI: 6.2-17.4%) (HR: 2.57; 95% CI: 1.48-4.45), while rhythm disorders developed in 27 patients with SSc with cumulative incidence of 27.3% (95% CI: 17.9-41.6%) vs. 43 non-SSc patients with cumulative incidence of 18.0% (95% CI: 12.3-26.4%) (HR: 1.62; 95% CI: 1.00-2.64). Age, pulmonary hypertension and smoking were identified as risk factors.

Conclusion

Patients with SSc have an increased risk of conduction and rhythm disorders both at disease onset and over time, compared to non-SSc patients. These findings warrant increased vigilance and screening for ECG abnormalities in SSc patients with pulmonary hypertension.

A case of a large leiomyomatous uterus with multiple arteriovenous malformations and subsequent high cardiac output state with severe four chamber cardiac enlargement

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Uterine arteriovenous malformations (AVMs) may be associated with leiomyomas.

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Uterine AVMs can lead to a high cardiac output state and cardiac dysfunction.

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Multidisciplinary management of uterine AVMs may prevent high output cardiac failure.

Uterine arteriovenous malformations (AVMs) are rare and potentially life-threatening. They can be congenital or acquired. Uterine artery embolization or hysterectomy are considered mainstays of management. AVMs can be associated with leiomyomas, and patients may require both procedures. We present a case of a 42-year-old woman with a massively enlarged leiomyomatous uterus supplied and drained by multiple large AVMs, leading to high cardiac output state with severe four chamber cardiac dilation. Management required a multidisciplinary team of interventional radiology, gynecologic oncology surgery, vascular surgery, cardiac anesthesiology, cardiology, and urology and a 2-day interventional approach of preoperative arterial embolization followed by hysterectomy.

Characteristics of Transgender Women Referred to Women's Heart Clinic

Introduction

Transgender women have been reported to have a high burden of cardiovascular disease (CVD) and risk factors based largely on surveys. Our aim was to describe the prevalence of CVD and associated comorbidities among a cohort of older transgender women referred to cardiology as part of their gender-affirming care.

Methods

This was a retrospective, cross-sectional study of transgender women at a single institution from 2017 to 2019.

Results

Fifty-two consecutive patients were included. The most common reasons for referral were cardiac risk factor management (45%) and pre-operative cardiac risk stratification prior to gender-affirming surgery (35%). The mean age was 57 ± 10 years, 87% were white, and 92% had insurance coverage. Forty-eight patients (92%) were taking gender-affirming hormone therapy; 5 had undergone breast augmentation, 4 had undergone orchiectomy, and 2 had undergone vaginoplasty. The most common comorbidities were depression and/or anxiety (63%), obesity (58%), and hyperlipidemia (54%). Excluding aldosterone antagonists, 46% were on cardiac medications; changes were recommended for 25% of patients: new prescriptions in 9, dose adjustments in 5, and discontinuations in 4. According to the pooled cohort equation, the 10-year risk of atherosclerotic CVD was 9.4 ± 7.7% when the study population was calculated as male and 5.2 ± 5.1% when calculated as female (p <0.001). For patients who completed exercise testing, the functional aerobic capacity was fair (77.6 ± 21.4%) when calculated as male and average (99.5 ± 27.5%) as female (p < .0001); there was inconsistency in sex used for calculating the result on the formal report.

Conclusions

Older transgender women may have an underestimated prevalence of CVD and its risk factors. More research is needed to identify cardiovascular health profiles, improve practice consistency, and establish normative values for transgender patients.

OP0102 DECLINE IN EXCESS RISK OF HEART FAILURE IN PATIENTS WITH RHEUMATOID ARTHRITIS IN RECENT YEARS

Background:

Heart failure (HF) is one of the most common cardiovascular conditions in patients with rheumatoid arthritis (RA). Previous studies showed a 2-fold excess risk of HF in RA versus the general population (1). Whether this has changed over time is not known. Longitudinal studies on trends in occurrence of HF in RA patients over time, and studies comparing trends in HF in RA versus the general population are lacking.

Objectives:

1) To assess trends in incidence of HF in patients with incident RA in 1980-2009; and 2) To compare incidence of HF in RA patients and population-based comparators without RA with RA incidence/ index date in 1980-2009.

Methods:

The study population comprised Olmsted County, Minnesota residents with incident RA (age ≥18 years, 1987 ACR criteria met in 1980-2009) and non-RA subjects from the same underlying population with similar age, sex and calendar year of index. All subjects were followed until death, migration, or 04/30/2019. Incident HF was defined using Framingham criteria. Patients with HF prior to RA incidence/index date were excluded. Cox proportional hazards models were used to compare incident HF events by decade, adjusting for age, sex and cardiovascular risk factors: smoking, obesity, diabetes mellitus, hypertension, dyslipidemia. Cumulative incidence of HF adjusted for death was also computed.

Results:

The study included 905 patients with RA (mean age 55.9 years; 69% female; median follow-up 13.4 years). The 10-year cumulative incidence of HF in RA cohort in the 1980s was 8.5% (95%CI 5.3-13.6%), 1990s was 10.8% (95%CI 7.7-15.1%), and 2000s was 7.1% (95%CI 4.9-10.3%). There was no difference in incidence of HF in 1990s (hazard ratio [HR] 0.91, 95% Confidence Interval [CI] 0.62-1.35) and 2000s (HR 0.73; 95%CI 0.46-1.18) compared to 1980s. Patients with incident RA were then compared to 903 individuals without RA (mean age 56.0 years; 69% female; median follow-up 13.8 years). The 10-year cumulative incidence of HF in these individuals in the 1980s was 7.4% (95%CI 4.5-12.3%), 1990s was 7.5% (95%CI 4.9-11.3%), and 2000s was 7.3% (95%CI 5.0-10.7%). Similar to RA, there was no statistically significant difference in incidence of HF in 1990s (HR 0.96, 95%CI 0.60-1.51) and 2000s (HR 0.75, 95%CI 0.44-1.30) compared to the 1980s. When comparing the risk of HF in RA and non-RA subjects, patients with RA in 2000s had no excess in HF risk as compared to the general population (HR 1.14, 95%CI 0.73-1.78, Figure 1). This is in contrast to the 2-fold excess risk of HF in patients with RA in 1980s (HR 2.20, 95%CI 1.44-3.34) and ~1.5-fold increase in risk of HF in 1990s (HR 1.54, 95%CI 1.04-2.29).

Figure 1.

Cumulative incidence of any HF event in RA and non-RA patients by decade of RA incidence/index

Conclusion:

We found a reduction in excess HF risk in patients with RA compared to individuals without RA in 2000s compared to 1980s. There were no statistically significant changes in incidence of HF in patients with RA and in individuals without RA over time. More studies are needed to understand the reasons and implications of these trends.

References:

[1]Nicola PJ, et al. The risk of congestive heart failure in rheumatoid arthritis: a population-based study over 46 years. Arthritis Rheum 2005;52:412–20.

Acknowledgements:

This work was supported by a grant from the National Institutes of Health, NIAMS (R01 AR46849) and NHLBI (HL120859). Research reported in this publication was supported by the National Institute of Aging of the National Institutes of Health under Award Number R01AG034676. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Disclosure of Interests:

Elena Myasoedova: None declared, John M Davis III Grant/research support from: Pfizer, Sara Achenbach: None declared, Kerry Wright: None declared, Reto Kurmann: None declared, Rekha Mankad: None declared, Veronique Roger: None declared, Cynthia S. Crowson: None declared

POS0836 CONDUCTION AND RHYTHM DISORDERS AMONG PATIENTS WITH SYSTEMIC SCLEROSIS: A US POPULATION BASED STUDY

Background:

Systemic sclerosis (SSc) can impact multiple areas of the heart through fibrotic and vascular processes; leading to variable cardiac involvement including electrocardiogram (ECG) abnormalities. Conduction and rhythm disorders are associated with worse prognosis in patients with SSc. (1, 2)

Objectives:

To study the incidence, risk factors and outcomes of conduction and rhythm disorders in a US population-based cohort of patients with SSc and non-SSc comparators from the same geographic area.

Methods:

A previously identified incident cohort of SSc patients (1980-2016) in a well-defined geographic area was compared to a randomly selected 2:1 cohort of age- and sex-matched non-SSc subjects from the same population base. Demographics, disease characteristics, cardiovascular risk factors and laboratory tests were abstracted by manual record review. ECGs and Holter ECGs were reviewed to determine the occurrence of any conduction or rhythm abnormalities. The need for cardiac interventions was also abstracted.

Results:

78 incident SSc cases and 156 non-SSc comparators were identified [age 56 years± 15.7, 91% female]. Prevalence of any conduction disorders before SSc diagnosis compared to non-SSc comparators was 15% vs. 7% (p=0.06), and any rhythm disorder was 18% vs. 13% (p=0.33). During a median follow up of 10.5 years in patients with SSc and 13.0 years in non-SSc comparators, conduction disorders developed in 25 SSc patients with a cumulative incidence (ci) of 20.5% (95% CI: 12.4-34.1%) compared to 28 non-SSc patients with ci of 10.4% (95% CI: 6.2-17.4%) (HR: 2.57; 95% CI: 1.48-4.45), while rhythm disorders developed in 27 SSc patients with ci of 27.3% (95% CI: 17.9-41.6%) vs 43 non-SSc patients with ci of 18.0% (95% CI: 12.3-26.4%) (HR: 1.62; 95% CI: 1.00-2.64). (Figure 1).

Conduction disorders in patients with SSc during follow up included: 1st-degree atrioventricular block (AVB) (n=12), 2nd-degree AVB (n=1), 3rd-degree AVB (n=1), right bundle branch block (n=10), left bundle branch block (n=4), bifascicular block (n=6), and prolonged-QT (n=13). Rhythm disorders included: atrial fibrillation (n=10), atrial flutter (n=4), supraventricular tachycardia (n=4), ventricular tachycardia (n=1), and premature ventricular contractions (n=16).

Pulmonary hypertension (PHT) was the only significant risk factor identified for development of both conduction and rhythm disorders (HR=8.38, 95% CI: 1.32-53.40 and HR=8.07, 95% CI: 1.60-40.74, respectively). Current smoking significantly increased the risk for development of rhythm disorders (HR=2.91, 95% CI: 1.19-7.12). Conduction and rhythm disorders were associated with increased mortality among patients with SSc (HR=7.60, 95% CI: 3.49-16.55 and HR=4.87, 95% CI: 2.28-10.42, respectively, after adjusting for age, sex and calendar year of diagnosis).

Conclusion:

Patients with SSc have a significantly higher prevalence of conduction disorders at disease onset than non-SSc comparators. During the course of their disease, their risk of developing conduction disorders is 2.6-fold, and risk of rhythm disorders is 1.6-fold increased, compared to non-SSc subjects.

PHT was significantly associated with increased risk of developing conduction and rhythm disorders among patients with SSc, a finding that should warrant increased vigilance and screening for ECG abnormalities in this population.

References:

[1]Tyndall A.J. et al. Ann Rheum Dis, 2010. 69(10): p. 1809-15.

[2]Desai C.S. et al. Curr Opin Rheumatol, 2011. 23(6): p. 545-54.

Figure 1.

Cumulative incidence of any conduction or any rhythm disorder in SSc (solid line) vs non-SSc comparators (dashed line).

Disclosure of Interests:

None declared

Elevated Prosthetic Valve Gradients: What to Consider When Determining an Etiology

DOPPLER echocardiography is a useful noninvasive tool for the assessment of cardiac hemodynamics. However, it is subject to limitations that can have important clinical implications, especially in the setting of valve prosthesis. Elevation in mean transvalvular gradient is a finding that has a variety of etiologies. One such etiology is the pressure-recovery (PR) phenomenon, a consequence of stream convergence and energy conversion across a narrowing, which is an artifact of Doppler echocardiographic calculations of valvular flow. The elevated gradient measured with Doppler echocardiography as a result of PR is not present on cardiac catheterization and does not represent true problematic valve hemodynamics. PR should be suspected with an elevated gradient on Doppler echocardiography with normal leaflet motion, especially in the setting of a small proximal aorta. Understanding and awareness of PR are important because PR can lead to overestimation of disease severity in the clinical setting.

Increased Risk of Valvular Heart Disease in Systemic Sclerosis: An Underrecognized Cardiac Complication

OBJECTIVE

Cardiac involvement is a poor prognostic marker in systemic sclerosis (SSc). While diastolic dysfunction, myocardial fibrosis, and arrhythmias are traditionally considered features of primary cardiac involvement in SSc, the incidence of valvular heart disease (VHD) is not well reported. Our objective was to examine the prevalence of VHD at the time of SSc diagnosis and incidence of VHD during follow-up compared to non-SSc subjects.

METHODS

Medical records of patients with suspicion of SSc were reviewed to identify incident cases. SSc subjects were matched 1:2 by age and sex to non-SSc subjects.

RESULTS

The study included 78 incident SSc cases and 156 non-SSc comparators (56 yrs [± 15.7], 91% female). A nearly 4-fold increase in the prevalence of moderate/severe VHD prior to SSc diagnosis compared to non-SSc subjects (6% vs 0%; P = 0.004) was identified. During follow-up, 18 SSc and 12 non-SSc patients developed moderate/severe VHD. The cumulative incidence of VHD at 10 years after SSc incidence/index was 17.9% (95% CI 10.7-29.9) in patients with SSc compared with 2.3% (95% CI 0.7-7.0) in non-SSc subjects (HR 4.23, 95% CI 2.03-8.83). Coronary artery disease was the only significant risk factor for VHD.

CONCLUSION

Patients with SSc have a 4-fold increase in the prevalence of moderate/severe VHD at diagnosis compared to non-SSc patients. They also have a 4-fold increased risk of developing moderate/severe VHD after diagnosis of SSc. Aortic stenosis and mitral regurgitation have a much higher prevalence in patients with SSc, besides secondary tricuspid regurgitation. Underlying mechanisms for this association require further elucidation.

Use of Hydroxychloroquine and Risk of Heart Failure in Patients With Rheumatoid Arthritis

OBJECTIVE

To examine the relationship between the use of hydroxychloroquine (HCQ) and risk of developing heart failure (HF) in rheumatoid arthritis (RA).

METHODS

In this nested case-control study, cases were Olmsted County, Minnesota residents with incident RA (based on 1987 American College of Rheumatology criteria) from 1980 to 2013 who developed HF after RA incidence. Each case was matched on year of birth, sex, and year of RA incidence with an RA control who did not develop HF. Data on HCQ use including start and stop dates, as well as dose changes, were reviewed and used to calculate HCQ duration and cumulative dose. Age-adjusted logistic regression models were used to examine the association between HCQ and HF.

RESULTS

The study identified 143 RA cases diagnosed with HF (mean age 65.8 yrs, 62% females) and 143 non-HF RA controls (mean age 64.5, 62% female). HCQ cumulative dose was not associated with HF (OR 0.96 per 100-g increase in cumulative dose, 95% CI 0.90-1.03). Likewise, no association was found for patients with a cumulative dose ≥ 300 g (OR 0.92, 95% CI 0.41-2.08). The HCQ duration of intake in years prior to index was not associated with HF (OR 0.98, 95% CI 0.91-1.05).

CONCLUSION

Use of HCQ was not associated with development of HF in patients with RA in this study. Further studies are needed to understand the effect of higher doses of HCQ on the development of HF in RA.

Evaluating the sensitivity of the ACC/AHA pooled cohort risk calculator to predict atherosclerotic cardiovascular events within 10 years: how many events are we failing to predict?

Background

The ACC/AHA Pooled Cohort Equation (PCE) for atherosclerotic cardiovascular disease (ASCVD) has been recommended as the initial step in cardiovascular risk assessment. The sensitivity of this tool to detect those who will develop ASCVD within 10-years, while considering age and sex groups, has not been extensively studied.

Methods

Using the Rochester Epidemiology Project (REP) we evaluated a community-based cohort of consecutive patients that sought primary care in Olmsted County, MN, between the years 1998–2000 and were followed up through March 1st 2016. Inclusion criteria were ages 40–79 and complete data to calculate the PCE. We excluded those with known ASCVD, atrial fibrillation or heart failure. Criteria were similar to those used to derive the PCE. Events were validated in duplicate and included fatal and non-fatal myocardial infarction and ischemic stroke. Patient information was ascertained using the record linkage system of the REP. Follow-up was truncated at 10 years. We assessed the ASCVD predicted risk (categorized as low &lt;5%, intermediate 5–9.9%, high 10–19.9%, and very high ≥20% risk) at baseline, in subjects having an ASCVD event within 10-years in the community across age (&lt;65 years) and sex categories. We also categorized ideal cardiovascular health as ≥4 metrics [non-smoker, body mass index &lt;25 kg/m2, and not having of elevated blood pressure (≥130/80 mmHg), LDL cholesterol (&gt;100 mg/dL), or fasting blood glucose (&gt;100 mg/dL), in the absence of a medical diagnosis or treatment].

Results

We included 30,042 adults, mean ± SD age 48.5±12.2 years, 54% women, with a median follow-up of 16.5±5.3 years. There were 1,555 ASCVD events (5.2%) at 10 years of follow-up. The performance of the PCE was similar to what was described in the original report (0.78 vs 0.79). Overall, among those who suffered an ASCVD, 54% of women and 41% of men were not high risk as predicted by PCE (Figure 1A). Most women (73%) &lt;65 years of age would had been considered low risk within 10-years before the event, and only 10% would have been considered to be high risks (Figure 1B). Nonetheless, women &lt;65 years who had an ASCVD event and low 10-year predicted ASCVD risk by PCE were less likely to have ideal cardiovascular health [55 (0.40%) vs 3884 (28.39%), p-value&lt;0.0001], when compared to women in the low risk category without an event.

Conclusion

The PCE fails to identify most women who will develop an ASCVD event, particularly women &lt;65 years of age. These results underscore the importance of using additional information when estimating ASCVD risk among women and the need for better cardiovascular risk prediction tools.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Mayo Clinic

A Tale of Two Valves: Bioprosthetic Aortic Valve Obstruction in Systemic Lupus Erythematosus and Antiphospholipid Antibody Syndrome

Patients with systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APLAS) are at risk for cardiac manifestations, specifically valvular heart disease requiring valve replacement. Bioprosthetic valve endocarditis is an important cause of valve failure, and it is important to keep a wide differential, especially in patients with preexisting SLE and APLAS. In this E-challenge, 2 cases of bioprosthetic aortic valve endocarditis are presented; 1 case describes infective bacterial endocarditis on an aortic prosthesis and the second describes a patient with SLE and APLAS who developed bioprosthetic valve obstruction secondary to vegetations, consistent with nonbacterial endocarditis and thrombus. Etiologies for bioprosthetic valve obstruction and evaluation by echocardiography are explored. The comparison between these 2 cases specifically highlights the importance of keeping a wide differential in endocarditis, prosthetic valve vegetations, and bioprosthetic valve obstruction.

Mitral Valve Prolapse Patients with Less than Moderate Mitral Regurgitation Exhibit Early Cardiac Chamber Remodeling

BACKGROUND

Mild physiologic mitral regurgitation (MR) is common in normal individuals. Patients with primary MR due to mitral valve prolapse (MVP) may also exhibit less than moderate MR. We sought to determine whether MVP patients with less than moderate MR displayed early cardiac chamber remodeling or factors related to early remodeling and whether early remodeling predicted MR progression.

METHODS

Consecutive MVP patients with less than moderate MR by proximal isovelocity surface area-derived effective regurgitant orifice < 20 mm2 and regurgitant volume < 30 mL, were matched for age and sex with non-MVP patients (controls) having less than moderate MR. Patients with moderate or greater dysfunctional left- or right-sided valves and left ventricular ejection fraction < 50% were excluded. We evaluated left ventricle (LV) and left atrium (LA) remodeling parameters (LV end-diastolic and end-systolic indexed diameters, LA volume-index, and LV mass-index) as well as determinants of remodeling. The last available transthoracic echocardiography was reviewed to identify progression to moderate-severe MR or more.

RESULTS

A total of 253 MVP patients with less than moderate MR were matched to 344 controls (P for age and sex, ≥.18) with less than moderate MR. Patients with MVP (mean effective regurgitant orifice and regurgitant volume, 12 ± 4 mm2 and 18 ± 6 mL, respectively) had more premature ventricular contractions (PVCs), larger LV and LA remodeling parameters, and more mild-to-moderate MR (all P < .0001). Multivariate linear regression models showed that larger LV remodeling parameters were independently associated with MVP and female sex but not MR severity (all P < .0001). The LA volume index was independently associated with MVP, age, and E/e' (all P < .0001). The LV mass index was associated with MVP, age, and hypertension (all P ≤ .002). Presence of PVCs was associated with LV end-systolic diameter ≥ 40 mm and indexed ≥ 22 mm2 (P = .005). Among 323 (54%) patients having subsequent transthoracic echocardiography, 17 patients (all MVP) progressed to moderate-severe MR or more at a median of 4.3 (interquartile range, 1.7-6.4) years. Isolated posterior leaflet prolapse was the single factor associated with MR progression (adjusted hazard ratio, 2.70; 95% CI, 0.99-7.34; P = .048) after adjustment for MR severity. At a median of 5.9 (interquartile range, 4.6-7.2) years of follow-up, female sex and MVP (vs controls) were protective factors for mortality.

CONCLUSIONS

Patients with less than moderate MR due to MVP exhibit early LV and LA remodeling, which does not predict MR progression or mortality. Left ventricle remodeling is associated with MVP, female sex, and presence of PVCs. Early chamber remodeling associated with MVP may be the phenotypical expression of a genetically mediated process and is at least partially related to PVCs.

Cardiovascular Risk Factors and Atherosclerotic Cardiovascular Events Among Incident Cases of Systemic Sclerosis: Results From a Population-Based Cohort (1980-2016)

OBJECTIVE

To characterize cardiovascular (CV) risk factors and outcomes among incident cases of systemic sclerosis (SSc) in a population-based cohort.

METHODS

Medical records of patients with SSc diagnosed in Olmsted County, Minnesota, between January 1, 1980, and December 31, 2016, were reviewed to identify 78 incident SSc cases. The comparators were 156 sex- and age-matched individuals from the same population. Data for SSc characteristics, traditional CV risk factors, and CV events were collected. Cumulative incidence was adjusted for the competing risk for death.

RESULTS

During a median follow-up of 9.8 (SSc) and 9.2 years (non-SSc), 21 patients with SSc and 17 patients without SSc developed CV events, corresponding to 10-year cumulative incidence of 24.4% and 15.2%, respectively. The risk for incident CV disease was increased by 2-fold (hazard ratio, 2.38; 95% CI, 1.28-4.43) in patients with SSc vs comparators, predominately due to coronary artery disease (hazard ratio, 2.35; 95% CI, 1.17-4.71). Mean body mass index and prevalence of diabetes mellitus were lower in SSc vs non-SSc. There was no significant difference in smoking, hypertension, or hyperlipidemia. Observed CV events were increased compared with CV events predicted by the Framingham Risk Score and American College of Cardiology/American Heart Association score with standardized incident ratios of 4.16 (95% CI, 2.16-7.99) and 5.69 (95% CI, 2.71-11.94), respectively.

CONCLUSION

Patients with SSc are at >2-fold increased risk for experiencing a CV event compared with persons without SSc. Framingham Risk Score and American College of Cardiology/American Heart Association score dramatically underestimate CV risk in SSc.

Antiphospholipid syndrome and the relationship between laboratory assay positivity and prevalence of non-bacterial thrombotic endocarditis: A retrospective cohort study

BACKGROUND

Nonbacterial thrombotic endocarditis (NBTE) is a potential complication of antiphospholipid syndrome (APS) manifesting as noninfectious lesions on one or more cardiac valves. There are limited tools to inform clinicians regarding which APS patients would benefit most from echocardiographic screening for this complication.

OBJECTIVES

We tested the hypothesis that the risk of both prevalent and incident NBTE is directly related to the number of positive laboratory assays for APS.

PATIENTS/METHODS

In this single-center, retrospective, cohort study design, consecutive patients with confirmed APS seen at Mayo Clinic Rochester, MN (1/1/1993-6/26/2016), were identified by searching a centralized electronic database. Demographic data, clinical presentation, echocardiographic features, laboratory findings, and survival data were scrutinized.

RESULTS

During the study period, 611 patients met the diagnostic criteria for APS and 386 (63%) underwent echocardiography. Of these, 58 (15%) were found to have NBTE. NBTE was more common in those with double (19.4%) and triple-positive laboratory criteria (27.0%) compared with single-positive disease (5.7%, P < .001). Survival free of NBTE diagnosis was significantly shorter in those patients with >1 positive laboratory assay (P < .01). Cox proportional hazard analysis suggests that patients with APS are more likely to be diagnosed with NBTE if they have >1 positive laboratory assay (relative risk 20.1; 95% confidence interval 1.3-316.6; P < .03).

CONCLUSION

Antiphospholipid syndrome carries a high prevalence of NBTE (15%). This prevalence is particularly high for patients with either double- or triple-positive laboratory criteria.

OP0024 USE OF HYDROXYCHLOROQUINE AND RISK OF HEART FAILURE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Hydroxychloroquine (HCQ) is a disease-modifying anti-rheumatic drug (DMARD) used as a long-term treatment for rheumatoid arthritis (RA) patients. Cardiotoxicity is a rare but potentially life-threatening side effect of HCQ and may present as conduction disorders, cardiomyopathy, and resulting heart failure (HF). The evidence of cardiotoxicity associated with the use of HCQ largely relies on case reports and case series while large cohort studies on the subject are lacking.

Objectives:

To examine the relationship between the use of HCQ and risk of developing HF in RA.

Methods:

In this nested case-control study, cases were Olmsted county, Minnesota residents with incident RA (based on 1987 ACR criteria) in 1980-2013 who developed HF after RA incidence. Each case was matched on year of birth, sex and year of RA incidence with an RA control who did not develop HF. Each non-HF control was assigned an index date corresponding to the HF diagnosis date of the case. Controls were allowed to later become cases to avoid bias. HF was defined using the Framingham criteria. Data on HCQ use including start and stop dates and dose changes was manually abstracted via medical record review, and used to calculate HCQ duration and cumulative dose. Age-adjusted logistic regression models were used to examine the association between HCQ and HF.

Results:

From a cohort of 1078 subjects, the study identified 143 RA cases diagnosed with HF (mean age 65.8, 62% females) and 143 non-HF RA controls (mean age 64.5, 62% female). Cases and controls had similar RA duration, proportion of patients positive for rheumatoid factor (RF) and/ or cyclic citrullinated antibody (CCP), body mass index, and smoking status (Table). The duration of HCQ use prior to the diagnosis of HF was 2.8 years in cases and 2.6 years in controls. A total of 71 cases and 69 controls used HCQ at some time before index date. Among these, the median (interquartile range) duration of HCQ use was 2.8 (0.6, 10.0) years for cases and 2.5 (0.7, 8.2) for controls. The median cumulative dose of HCQ was 371 g and 302 g in cases and controls, respectively, with 55% of cases receiving a cumulative dose of ≥ 300 g compared to 54% in controls. HCQ cumulative dose was not associated with HF (Odds Ratio [OR]: 0.96 per 100g increase in cumulative dose, 95% confidence interval [95% CI]: 0.90-1.03). Likewise, no association was found for patients with a cumulative dose ≥300g (OR 0.92, 95% CI 0.41-2.08). The duration of use of HCQ prior to index was not associated with HF (OR 0.98, 95% CI 0.91-1.05). Retinal toxicity rates were similar in cases and controls.

Table 1.

Characteristics of patients with rheumatoid arthritis with and without heart failure.

VariableHFnon-HFAge at RA diagnosis (years)65.8 ± 12.364.5 ± 12.5Female62%62%RA duration at baseline (years)11.3 ± 8.510.3 ± 8.2RF positive66%65%CCP positive46%53%RF/ CCP positive68%66%BMI (at RA diagnosis)28.6 ± 6.527.7 ± 5.4Smoking status at RA incidenceFormer45%41%Current22%22%

Conclusion:

Use of HCQ was not associated with development of HF in patients with RA in this study. While there was no statistically significant association between the cumulative dose of HCQ and HF, the confidence interval for HCQ dose ≥300 g was wide suggesting that more studies are needed to understand the impact of higher doses of HCQ on development of HF in RA.

Disclosure of Interests:

Ahmed Sorour: None declared, Youssef Shahin: None declared, Cynthia S. Crowson Grant/research support from: Pfizer research grant, Reto Kurmann: None declared, Sara Achenbach: None declared, Rekha Mankad: None declared, Elena Myasoedova: None declared

Disparities in Cardiac Care of Women: Current Data and Possible Solutions

PURPOSE OF REVIEW

Cardiovascular disease remains the leading cause of death in women. The goal of this review is to address known disparities in cardiovascular care with regard to diagnosis and treatment of heart disease in women.

RECENT FINDINGS

Gender-specific differences in regard to the incidence, treatment, and outcomes of common cardiovascular pathology are increasingly recognized. Particular attention to ischemic heart disease, arrhythmia, congestive heart failure, and structural heart disease are reviewed in this article. There is a clear racial and ethnic discrepancy among women which is particularly concerning with a progressively diverse patient population. Medical and surgical treatment differences between men and women must be addressed by providers in order to optimize long-term outcomes among all patients. Understanding the unique cardiovascular risk profile and barriers to optimal treatment outcomes in women is imperative to eliminate the current disparities in cardiovascular disease.

Atherosclerotic vascular disease in the autoimmune rheumatologic woman

Autoimmune rheumatologic conditions have increased cardiovascular morbidity and mortality compared to the general population. Many of these diseases occur more commonly in women, such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis, and Sjogren's. Most of the literature that has identified the link between autoimmune diseases and atherosclerotic cardiovascular disease (ASCVD) has been regarding patients with RA and SLE. The reason for the increased ASCVD is related to both traditional risk factors for atherosclerosis and nontraditional risk factors such as the burden of inflammation. Presently, our ability to adequately determinecardiovascular risk in the autoimmune patient is subpar, as scoring systems fail to take into account the role of inflammation. No present guidelines exist that take into account the increased burden of cardiovascular disease in this complex patient cohort.

Progression rate of severity of aortic stenosis in patients with rheumatoid arthritis

OBJECTIVE

Valvular heart disease is common in patients with rheumatoid arthritis (RA). However, there is uncertainty about how often to perform echocardiographic surveillance in this population. The objective of this study was to assess the progression rate of mild and moderate aortic stenosis (AS) in patients with RA.

METHODS

A population-based cohort of patients with RA and either mild (2.0-2.9 m/second) or moderate (3.0-3.9 m/second) AS was identified. Demographic, clinical, and echocardiographic data were collected. Annual progression rate of AS was then calculated for the study cohort and the impact of pertinent RA variables on progression rate determined.

RESULTS

Sixty-eight patients with RA and mild or moderate AS met the inclusion requirements. Peak aortic valve (AV) velocity and mean AV gradient increased during the study period, whereas AV area decreased, consistent with progression of AS (P<.001). Mean (SD) annual increase in peak AV jet velocity was 0.05 m/second (0.01) and in mean AV gradient was 1.0 mm Hg (0.18). Mean annual decrease in AV area was 0.04 (0.01) cm² . The progression rate of AS was higher in patients with increased erythrocyte sedimentation rates (ESR) (P=.001).

CONCLUSIONS

The rate of AS progression in the RA population was higher in patients with increased ESR but less than that of the reported rate of AS progression in the general population. Although the cause for this finding is uncertain, these results suggest that patients with RA who have mild or moderate AS should undergo echocardiographic surveillance for disease progression similar to that of the general population.

Cardiovascular risk assessment in patients with rheumatoid arthritis: a correlative study of noninvasive arterial health testing

This study aimed to determine the relationship between noninvasive measures of arterial health and both estimated 10-year cardiovascular risk and measures of disease activity over time in established rheumatoid arthritis. Fifty rheumatoid arthritis patients underwent noninvasive arterial health testing (brachial artery reactivity, aortic augmentation index [AIx], pulse wave velocity, carotid artery intima-media thickness, and carotid artery plaque presence) and assessment of clinical disease activity (tender or swollen joint counts, Clinical Disease Activity Index [CDAI], and Health Assessment Questionnaire II [HAQ-II]). Clinical measures during 3 years before the study visit were averaged. Arterial health testing was compared with the American Heart Association/American College of Cardiology (AHA/ACC) Pooled Cohort Equation. Spearman methods identified correlations between disease activity measures, cardiac biomarkers, and arterial health parameters. Among the patients (mean age, 57.5 years), disease activity was moderate (mean [SD] CDAI, 16.9 [15.3]). At the study visit, corrected aortic augmentation index correlated with CDAI (r = 0.37, P = .009) and HAQ-II (r = 0.33, P = .02). AIx correlated with time-averaged tender joint count (r = 0.37, P = .008), CDAI (r = 0.36, P = .01), HAQ-II (r = 0.36, P = .01), swollen joint count (r = 0.36, P = .10), patient global assessment (r = 0.33, P = .02), physician global assessment (r = 0.35, P = .01), and pain score (r = 0.38, P = .007). The AHA/ACC low-risk group (<5% 10-year risk) had highest prevalence of carotid plaques. Arterial health testing may identify increased risk of cardiovascular disease compared with risk obtained through AHA/ACC Pooled Cohort Equation. Measures of arterial stiffness correlate with the burden of disease activity over time.

Cardiac tumors: echo assessment

Cardiac tumors are exceedingly rare (0.001–0.03% in most autopsy series). They can be present anywhere within the heart and can be attached to any surface or be embedded in the myocardium or pericardial space. Signs and symptoms are nonspecific and highly variable related to the localization, size and composition of the cardiac mass. Echocardiography, typically performed for another indication, may be the first imaging modality alerting the clinician to the presence of a cardiac mass. Although echocardiography cannot give the histopathology, certain imaging features and adjunctive tools such as contrast imaging may aid in the differential diagnosis as do the adjunctive clinical data and the following principles: (1) thrombus or vegetations are the most likely etiology, (2) cardiac tumors are mostly secondary and (3) primary cardiac tumors are mostly benign. Although the finding of a cardiac mass on echocardiography may generate confusion, a stepwise approach may serve well practically. Herein, we will review such an approach and the role of echocardiography in the assessment of cardiac masses.

Focused Cardiovascular Care for Women: The Need and Role in Clinical Practice

Over the past decade, an emerging clinical research focus on cardiovascular (CV) disease (CVD) risk in women has highlighted sex-specific factors that are uniquely important in the prevention and early detection of coronary atherosclerosis in women. Concurrently, a 30% decrease in the number of female deaths from CVD has been observed. Despite this, CVD continues to be the leading cause of death in women, outnumbering deaths from all other causes combined. Clinical practice approaches that focus on the unique aspects of CV care for women are needed to provide necessary resources for the prevention, diagnosis, and treatment of CVD in women. In addition to increasing opportunities for women to participate in CV research, Women's Heart Clinics offer unique settings in which to deliver comprehensive CV care and education, ensuring appropriate diagnostic testing, while monitoring effectiveness of treatment. This article reviews the emerging need and role of focused CV care to address sex-specific aspects of diagnosis and treatment of CVD in women.

Atherosclerotic vascular disease in the autoimmune rheumatologic patient

Autoimmune diseases, such as rheumatoid arthritis and systemic lupus erythematosus, have a strong association with an increased risk of atherosclerotic cardiovascular diseases (ASCVD), particularly ischemic heart disease (IHD). A majority of the autoimmune conditions occur predominantly in women, and as women continue to experience a higher cardiovascular mortality compared to men, this potential added risk factor must be recognized. Inflammation and immune mechanisms have been shown to be an underlying mechanism for the development of atherosclerosis, thus sharing a common mechanism with rheumatologic conditions. There is an under recognition, in both patient and physician, of the increased cardiovascular (CV) risk within the autoimmune population, with present CV risk profile algorithms performing poorly in these patients. Traditional risk factors play a role in the development of IHD in the autoimmune patient, but their overall significance is unclear and does not fully explain the elevated CV risk. The role of inflammation and risk factors in autoimmune conditions, and their link to the elevated CV risk will be explored within this article.

Spontaneous coronary artery dissection: is there a metabolic association?

Spontaneous coronary artery dissection is an uncommon cause of chest pain and acute myocardial infarction, occurring most classically in young women without cardiovascular risk factors. We present a case of a man presenting with chest pain and arrhythmia found to have multivessel spontaneous coronary artery dissection and hyperhomocysteinemia and we raise the possibility of a potential link between the two conditions.

Sex differences in aortic valve calcification measured by multidetector computed tomography in aortic stenosis

BACKGROUND

Aortic valve calcification (AVC) is the intrinsic mechanism of valvular obstruction leading to aortic stenosis (AS) and is measurable by multidetector computed tomography. The link between sex and AS is controversial and that with AVC is unknown.

METHODS AND RESULTS

We prospectively performed multidetector computed tomography in 665 patients with AS (aortic valve area, 1.05±0.35 cm(2); mean gradient, 39±19 mm Hg) to measure AVC and to assess the impact of sex on the AVC-AS severity link in men and women. AS severity was comparable between women and men (peak aortic jet velocity: 4.05±0.99 versus 3.93±0.91 m/s, P=0.11; aortic valve area index: 0.55±0.20 versus 0.56±0.18 cm(2)/m(2); P=0.46). Conversely, AVC load was lower in women versus men (1703±1321 versus 2694±1628 arbitrary units; P<0.0001) even after adjustment for their smaller body surface area or aortic annular area (both P<0.0001). Thus, odds of high-AVC load were much greater in men than in women (odds ratio, 5.07; P<0.0001). Although AVC showed good associations with hemodynamic AS severity in men and women (all r>0.67; P<0.0001), for any level of AS severity measured by peak aortic jet velocity or aortic valve area index, AVC load, absolute or indexed, was higher in men versus women (all P≤0.01).

CONCLUSIONS

In this large AS population, women incurred similar AS severity than men for lower AVC loads, even after indexing for their smaller body size. Hence, the relationship between valvular calcification process and AS severity differs in women and men, warranting further pathophysiological inquiry. For AS severity diagnostic purposes, interpretation of AVC load should be different in men and in women.

Cardiovascular disease in older women: a challenge in diagnosis and treatment

Cardiovascular disease is the leading cause of death in women and more heart disease is present in elderly women than men. Risk factors for heart disease affect men and women differently, with a greater impact of diabetes, hyperlipidemia and smoking in women. Diagnosis of heart disease can be more challenging in women, especially when elderly, as symptoms may be vague. Understanding the appropriate use of diagnostic testing and appropriate treatment is essential, given the high burden of disease in elderly women. This article will discuss the current guidelines for diagnosis and therapy of heart disease in women and will discuss the appropriate role of prevention strategies.

Regional myocardial strain before and after mitral valve repair for severe mitral regurgitation

Magnetic resonance tagging (MRI) can be used to study intramyocardial trains in human in vivo. We wished to determine whether patients with severe mitral regurgitation demonstrate subtle myocardial contractile dysfunction despite normal left ventricular (LV) ejection fraction (EF) and how, mitral valve repair (MVR) may preserve EF in such patients. MRI was performed on seven patients with severe mitral regurgitation (mean age +/- SD, 65+/-13 years) and normal EF day 1 (range, 0-8 days) before (Pre) and week 8+/-3 after (Post) MVR and on nine normal volunteers (mean age, 32+/-4). LV mass index (LVMI), end-diastolic and end systolic volume, mass/volume ratio, EF, and sphericity index were measured Pre and Post. Two-dimensional strain analysis of MR tagged images was performed and expressed as L1 (greatest systolic lengthening, radial in normal subjects), L2 (greatest systolic shortening, circumferential in normals), and beta (angular deviation of L1 from the radial direction). LVMI fell from 142+/-38 g/m2 Pre to 117+/-44 g/m2 Post (p < or = 0.008) as did LV end-diastolic volume (117+/-26 to 69+/-12 ml, p < or = 0.003), whereas EF remained unchanged (59+/-7% at both time points). LV mass/volume ratio increasedfrom 2.2+/-0.3 g/ml Pre to 3.1+/-0.4 g/ml Post (p < or = 0.02) and sphericity index fell from 0.86+/-0.10 to 0.71+/-0.13 (p = 0.02). In the short axis, L1 was greater in patients with mitral regurgitation than normal subjects (19+/-9% vs 16+/-6%, p < or = 0.003) and tended to increase further after MVR (21+/-8%, p < or = 0.06 vs. Pre). Beta was abnormal in mitral regurgitation (19+/-8 vs. 12+/-8 degrees in control subjects, p < 0.0001) and remained abnormal after MVR (19+/-9 degrees). L2 in the short axis was depressed in mitral regurgitation compared with control subjects (12+/-6% vs. 21+/-6%, p < or = 0.001) and was further depressed after MVR (9+/-7%, p < 0.001 vs. Pre). As detected by MRI, regional myocardial strains are abnormal in severe mitral regurgitation despite normal EF, characterized by increased short-axis systolic lengthening that is abnormally directed and by reduced shortening. After MVR, the further increase in short-axis lengthening may preserve EF despite its abnormal direction and a fall in shortening. The increase in short-axis lengthening may be due in part to the reduction in LV sphericity after MVR.