Effects of temperature and humidity on cerebrovascular disease hospitalization in a super-aging society

Weather conditions influence the incidence of cardiovascular disease. However, few studies have investigated the association between weather temperature and humidity and cerebrovascular disease hospitalizations in a super-aging society. We included 606,807 consecutive patients with cerebrovascular disease admitted to Japanese acute-care hospitals between 2015 and 2019. The primary outcome was the number of cerebrovascular disease hospitalizations per day. Multilevel mixed-effects linear regression models were used to estimate the association of mean temperature and humidity, 1 day before hospital admission, with cerebrovascular disease hospitalizations, after adjusting for air pollution, hospital, and patient demographics. Lower mean temperatures and humidity < 70% or humidity ≧ 70% are associated with an increased incidence of cerebrovascular disease hospitalization (coefficient, - 1.442 [- 1.473 to - 1.411] per °C, p < 0.001, coefficient, - 0.084 [- 0.112 to - 0.056] per%, p < 0.001, and coefficient, 0.136 [0.103 to 0.168] per %, p < 0.001, respectively). Lower mean temperatures and extremely lower or higher humidity are associated with an increased incidence of cerebrovascular disease hospitalization in a super-aging society.

Prognostic Value of Electrocardiographic Left Ventricular Hypertrophy After Transcatheter Aortic Valve Implantation: Insights from the OCEAN-TAVI Registry

Electrocardiogram (ECG) left ventricular hypertrophy (LVH) is associated with the prognosis of patients with aortic stenosis. However, the impact of the presence or absence of ECG-LVH on the clinical outcomes after transcatheter aortic valve implantation (TAVI) is limited. This study aimed to assess the prognostic value of ECG-LVH among patients with aortic stenosis treated by TAVI. A total of 1,667 patients who underwent TAVI were prospectively enrolled into the OCEAN-TAVI (Optimized CathEter vAlvular iNtervention-Transcatheter Aortic Valve Implantation) registry. A total of 1,446 patients (mean age 84 years; 29.9% men) were analyzed. The Sokolow-Lyon index was used to determine the presence of ECG-LVH. LVH was also assessed using transthoracic echocardiography (TTE). We investigated the association between ECG-LVH and all-cause and cardiovascular mortality. This study identified ECG-LVH and TTE-LVH in 743 (51.5%) and 1,242 patients (86.0%), respectively. The Kaplan-Meier analysis revealed that all-cause mortality was significantly higher among patients without ECG-LVH than among those with ECG-LVH (log-rank p <0.001). In the multivariable analysis, the absence of ECG-LVH was independently associated with all-cause mortality (hazard ratio 1.98, 95% confidence interval 1.39 to 2.82, p <0.001), regardless of the presence or absence of TTE-LVH. Furthermore, the presence of TTE-LVH with the absence of ECG-LVH was observed in 575 patients (40%), which was associated with cardiovascular mortality (hazard ratio 2.84, 95% confidence interval 1.56 to 5.17, p <0.001). In conclusion, the absence of ECG-LVH was independently associated with an increased risk of all-cause mortality after TAVI. Risk stratification using both ECG-LVH and TTE-LVH is a useful predictor of adverse clinical outcomes after TAVI.

Cardiovascular Interactions of Renin-Angiotensin-Aldosterone System Assessed by Cardiac Magnetic Resonance: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

The effects of the renin-angiotensin-aldosterone system in cardiovascular system have been described based on small studies. The aim of this study was to evaluate the relationship between aldosterone and plasma renin activity (PRA) and cardiovascular structure and function.

METHODS

We studied a random sample of Multi-Ethnic Study of Atherosclerosis participants who had aldosterone and PRA blood assays at 2003-2005 and underwent cardiac magnetic resonance at 2010. Participants taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers were excluded.

RESULTS

The aldosterone group was composed by 615 participants, mean age 61.6 ± 8.9 years, while the renin group was 580 participants, mean age 61.5 ± 8.8 years and both groups had roughly 50% females. In multivariable analysis, 1 SD increment of log-transformed aldosterone level was associated with 0.07 g/m2 higher left ventricle (LV) mass index (P = 0.04) and 0.11 ml/m2 higher left atrium (LA) minimal volume index (P < 0.01). Additionally, higher log-transformed aldosterone was associated with lower LA maximum strain and LA emptying fraction (P < 0.01). Aldosterone levels were not significantly associated with aortic measures. Log-transformed PRA was associated with lower LV end diastolic volume index (β standardized = 0.08, P = 0.05). PRA levels were not significantly associated with LA and aortic structural or functional differences.

CONCLUSIONS

Higher levels of aldosterone and PRA are associated with concentric LV remodeling changes. Moreover, aldosterone was related to deleterious LA remodeling changes.

Cardiovascular interactions of renin angiotensin aldosterone system assessed by cardiac magnetic resonance: The Multi-Ethnic Study of Atherosclerosis

OBJECTIVE

The effects of the Renin Angiotensin Aldosterone System in cardiovascular system has been described based on small studies. The aim of this study was to evaluate the relationship between aldosterone and plasma renin activity and cardiovascular structure and function.

METHODS

We studied a random sample of Multi-Ethnic Study of Atherosclerosis participants who had aldosterone and plasma renin activity blood assays at 2003-2005 and underwent cardiac magnetic resonance at 2010. Participants taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers were excluded.

RESULTS

The aldosterone group was composed by 615 participants, mean age 61.6 ± 8.9 years, while the renin group was 580 participants, mean age 61.5 ± 8.8 years and both groups had roughly 50% females. In multivariable analysis, 1 SD increment of log-transformed aldosterone level was associated with 0.07 g/m 2 higher left ventricle mass index (p=0.04) and 0.11 ml/m 2 higher left atrium minimal volume index (p < 0.01). Additionally, higher log-transformed aldosterone was associated with lower left atrium maximum strain and left atrium emptying fraction (βstandardized = -0.12, p < 0.01 and - 0.15, p < 0.01, respectively). Aldosterone levels were not significantly associated with aortic measures. Log-transformed plasma renin activity was associated with lower left ventricle end diastolic volume index (βstandardized = 0.08, p=0.05). Plasma renin activity levels were not significantly associated with left atrium and aortic structural or functional differences.

CONCLUSIONS

Higher levels of aldosterone and plasma renin activity are associated with concentric left ventricle remodeling changes. Moreover, aldosterone was related to deleterious left atrium remodeling changes.

Efficacy and Safety of Home-Based Cardiac Telemonitoring Rehabilitation in Patients After Transcatheter Aortic Valve Implantation: Single-Center Usability and Feasibility Study

BACKGROUND

No consensus exists on the efficacy of home-based cardiac rehabilitation (CR) in patients who have undergone transcatheter aortic valve implantation (TAVI). Additionally, there are no reports on home-based cardiac telemonitoring rehabilitation (HBTR) in patients after TAVI.

OBJECTIVE

We aimed to investigate the efficacy of HBTR in patients who have undergone TAVI.

METHODS

This single-center preliminary study introduced HBTR to patients after TAVI, and the efficacy outcomes of the rehabilitation method were compared to that of a historical control cohort. The historical control cohort (control group) consisted of 6 consecutive patients who underwent ordinary outpatient CR after TAVI from February 2016 to March 2020. Patients who participated in the HBTR program were only recruited after the TAVI procedure and before discharge between April 2021 and May 2022. In the first 2 weeks after TAVI, patients underwent outpatient CR and were trained using telemonitoring rehabilitation systems. Thereafter, patients underwent HBTR twice a week for 12 weeks. The control group performed standard outpatient CR at least once a week for 12 to 16 weeks. Efficacy was assessed using peak oxygen uptake (VO₂) prior to and after CR.

RESULTS

Eleven patients were included in the HBTR group. All patients underwent 24 HBTR sessions during the 12-week training period, and no adverse events were observed. The control group participants performed 19 (SD 7) sessions during the training period, and no adverse events were observed. Participants in the HBTR and control groups had a mean age of 80.4 (SD 6.0) years and 79.0 (SD 3.9) years, respectively. In the HBTR group, preintervention and postintervention peak VO₂ values were 12.0 (SD 1.7) mL/min/kg and 14.3 (SD 2.7) mL/min/kg (P=.03), respectively. The peak VO₂ changes in the HBTR and control groups were 2.4 (SD 1.4) mL/min/kg and 1.3 (SD 5.0) mL/min/kg (P=.64), respectively.

CONCLUSIONS

Home-based CR using a telemonitoring system is a safe outpatient rehabilitation method. Its efficacy is not inferior to that of standard CR in patients who have undergone TAVI.

TRIAL REGISTRATION

Japan Registry of Clinical Trials jRCTs032200122; https://jrct.niph.go.jp/latest-detail/jRCTs032200122.

Medical care provision at the venue of the weightlifting event of the Tokyo 2020 Olympic Games

Purpose

This study aimed to investigate the medical care provided at the venue of the weightlifting event of the Tokyo 2020 Olympic Games.

Methods

We retrospectively evaluated athletes who availed of medical services at the venue during the weightlifting event of the Tokyo 2020 Olympic Games. In total, 194 athletes participated in the weightlifting competition.Injuries and illnesses were classified into cases handled without physician or cases requiring medical examination by a physician. These were tabulated for each examination location (athlete medical station, field of play [FOP], first-aid station of training floor or warm-up area).

Results

Throughout the event, a cumulative total of 132 people used the venue medical services. Nine athletes required medical attention at the athlete medical stations. Of these nine cases, six occurred on the training floor. In the FOP, nine athletes were examined. Two experienced light-headedness, two had knee pain, and the rest had other symptoms. No athletes wanted to undergo medical examination at the athlete medical station. 89 medical procedures were performed in the first-aid station on the training floor, including 52 tapings and 37 ice compressions, and the most frequent body part which needed treatment was the knee, followed by the fingers. At the first-aid station on the match floor, 25 medical procedures were performed, including 17 ice compressions, 5 haemostasis, and 4 tapings. The body parts that most frequently needed treatment were the fingers, knees, and lower legs.

Conclusion

Several athletes needed treatment; however, only a few required medical care from a physician.

Angioscopic Evaluation of Atrial Septal Defect Closure Device Neo-Endothelialization

Background

Current guidelines recommend at least 6 months of antithrombotic therapy and antibiotic prophylaxis after septal‐occluding device deployment in transcatheter closure of atrial septal defect. It has been estimated that it takes ≈6 months for complete neo‐endothelialization; however, neo‐endothelialization has not previously been assessed in vivo in humans.

Methods and Results

The neointimal coverage of septal occluder devices was evaluated 6 months after implantation in 15 patients by angioscopy from the right atrium. Each occluder surface was divided into 9 areas; the levels of endothelialization in each area were semiquantitatively assessed by 4‐point grades. Device neo‐endothelialization was sufficient in two thirds of patients, but insufficient in one third. In the comparison between patients with sufficiently endothelialized devices of average grade score ≥2 (good endothelialization group, n=10) and those with poorly endothelialized devices of average grade score <2 (poor endothelialization group, n=5), those in the poor endothelialization group had larger devices deployed (27.0 mm [25.0–31.5 mm] versus 17.0 mm [15.6–22.5 mm], respectively) and progressive right heart dilatation. The endothelialization was poorer around the central areas. Moreover, the prevalence of thrombus formation on the devices was higher in the poorly endothelialized areas than in the sufficiently endothelialized areas (Grade 0, 94.1%; Grade 1, 63.2%; Grade 2, 0%; Grade 3, 1.6%).

Conclusions

Neo‐endothelialization on the closure devices varied 6 months after implantation. Notably, poor endothelialization and thrombus attachment were observed around the central areas and on the larger devices.

Association between acute myocardial infarction-to-cardiac rupture time and in-hospital mortality risk: a retrospective analysis of multicenter registry data from the Cardiovascular Research Consortium-8 Universities (CIRC-8U)

Despite the known association of cardiac rupture with acute myocardial infarction (AMI), it is still unclear whether the clinical characteristics are associated with the risk of in-hospital mortality in patients with AMI complicated by cardiac rupture. The purpose of this study was to investigate the association between the time of cardiac rupture occurrence and the risk of in-hospital mortality after AMI. We conducted a retrospective analysis of multicenter registry data from eight medical universities in Eastern Japan. From 10,278 consecutive patients with AMI, we included 183 patients who had cardiac rupture after AMI, and examined the incidence of in-hospital deaths during a median follow-up of 26 days. Patients were stratified into three groups according to the AMI-to-cardiac rupture time, namely the > 24-h group (n = 111), 24-48-h group (n = 20), and < 48-h group (n = 52). Cox proportional hazards regression analysis was used to estimate the hazard ratio (HR) and the confidence interval (CI) for in-hospital mortality. Around 87 (48%) patients experienced in-hospital death and 126 (67%) underwent a cardiac surgery. Multivariable Cox regression analysis revealed a non-linear association across the three groups for mortality (HR [CI]; < 24 h: 1.0, reference; 24-48 h: 0.73 [0.27-1.86]; > 48 h: 2.25 [1.22-4.15]) after adjustments for age, sex, Killip classification, percutaneous coronary intervention, blood pressure, creatinine, peak creatine kinase myocardial band fraction, left ventricular ejection fraction, and type of rupture. Cardiac surgery was independently associated with a reduction in the HR of mortality (HR [CI]: 0.27 [0.12-0.61]) and attenuated the association between the three AMI-to-cardiac rupture time categories and mortality (statistically non-significant) in the Cox model. These data suggest that the AMI-to-cardiac rupture time contributes significantly to the risk of in-hospital mortality; however, rapid diagnosis and prompt surgical interventions are crucial for improving outcomes in patients with cardiac rupture after AMI.

Influence of coronary artery disease and percutaneous coronary intervention on mid-term outcomes in patients with aortic valve stenosis treated with transcatheter aortic valve implantation

Background

A high frequency of coronary artery disease (CAD) is reported in patients with severe aortic valve stenosis (AS) who undergo transcatheter aortic valve implantation (TAVI). However, the optimal management of CAD in these patients remains unknown.

Hypothesis

We hypothesis that AS patients with TAVI complicated by CAD have poor prognosis. His study evaluates the prognoses of patients with CAD and severe AS after TAVI.

Methods

We divided 186 patients with severe AS undergoing TAVI into three groups: those with CAD involving the left main coronary (LM) or proximal left anterior descending artery (LAD) lesion (the CAD[LADp] group), those with CAD not involving the LM or a LAD proximal lesion (the CAD[non‐LADp] group), and those without CAD (Non‐CAD group). Clinical outcomes were compared among the three groups.

Results

The CAD[LADp] group showed a higher incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) and all‐cause mortality than the other two groups (log‐rank p = .001 and p = .008, respectively). Even after adjustment for STS score and percutaneous coronary intervention (PCI) before TAVI, CAD[LADp] remained associated with MACCE and all‐cause mortality. However, PCI for an LM or LAD proximal lesion pre‐TAVI did not reduce the risk of these outcomes.

Conclusions

CAD with an LM or LAD proximal lesion is a strong independent predictor of mid‐term MACCEs and all‐cause mortality in patients with severe AS treated with TAVI. PCI before TAVI did not influence the outcomes.

Weather temperature and the incidence of hospitalization for cardiovascular diseases in an aging society

Weather temperatures affect the incidence of cardiovascular diseases (CVD), but there is limited information on whether CVD hospitalizations are affected by changes in weather temperatures in a super-aging society. We aimed to examine the association of diurnal weather temperature changes with CVD hospitalizations. We included 1,067,171 consecutive patients who were admitted to acute-care hospitals in Japan between April 1, 2012 and March 31, 2015. The primary outcome was the number of CVD hospitalizations per day. The diurnal weather temperature range (DTR) was defined as the minimum weather temperature subtracted from the maximum weather temperature on the day before hospitalization. Multilevel mixed-effects linear regression models were used to estimate the association of DTR with cardiovascular hospitalizations after adjusting for weather, hospital, and patient demographics. An increased DTR was associated with a higher number of CVD hospitalizations (coefficient, 4.540 [4.310–4.765]/°C change, p < 0.001), with greater effects in those aged 75–89 (p < 0.001) and ≥ 90 years (p = 0.006) than among those aged ≤ 64 years; however, there were no sex-related differences (p = 0.166). Greater intraday weather temperature changes are associated with an increased number of CVD hospitalizations in the super-aging society of Japan, with a greater effect in older individuals.

Association of PM2.5 exposure with hospitalization for cardiovascular disease in elderly individuals in Japan

Although exposure to particulate matter with aerodynamic diameters ≤ 2.5 µm (PM_2.5) influences cardiovascular disease (CVD), its association with CVD-related hospitalizations of super-aged patients in Japan remains uncertain. We investigated the relationship between short-term PM_2.5 exposure and CVD-related hospitalizations, lengths of hospital stays, and medical expenses. We analyzed the Japanese national database of patients with CVD (835,405) admitted to acute-care hospitals between 2012 and 2014. Patients with planned hospitalizations and those with missing PM_2.5 exposure data were excluded. We classified the included patients into five quintiles based on their PM_2.5 exposure: PM-5, -4, -3, -2, and -1 groups, in descending order of concentration. Compared with the PM-1 group, the other groups had higher hospitalization rates. The PM-3, -4, and -5 groups exhibited increased hospitalization durations and medical expenses, compared with the PM-1 group. Interestingly, the hospitalization period was longer for the ≥ 90-year-old group than for the ≤ 64-year-old group, yet the medical expenses were lower for the former group. Short-term PM_2.5 exposure is associated with increased CVD-related hospitalizations, hospitalization durations, and medical expenses. The effects of incident CVDs were more marked in elderly than in younger patients. National PM_2.5 concentrations should be reduced and the public should be aware of the risks.

Impact of perioperative change in physical function on midterm outcomes after transcatheter aortic valve implantation

Preoperative frailty diminishes the potential for functional recovery after transcatheter aortic valve implantation (TAVI). However, perioperative changes in physical status and their impact on prognosis after TAVI have not previously been reported. Therefore, this study aimed to investigate whether perioperative changes in physical function affect prognosis in patients undergoing TAVI. We retrospectively reviewed 257 patients who underwent TAVI. The Short Physical Performance Battery (SPPB), an objective physical status assessment tool, was evaluated pre- and post-TAVI. Patients were divided into two groups: (i) patients whose SPPB score declined in the perioperative period (the decline group) and (ii) patients whose SPPB score did not decline in the perioperative period (the non-decline group). The primary endpoint was unplanned hospitalization owing to heart failure or cardiovascular death following TAVI. The mean follow-up period was 385 ± 151 days, mean age was 83.2 ± 5.8 years, and 67% of the patients were women. Sixteen patients required readmission owing to heart failure, and seven experienced cardiovascular-related death. Kaplan-Meier analysis revealed that the event-free rate was significantly lower in the decline group (log-rank, p = 0.006). A stepwise multivariate logistic regression analysis showed that a perioperative change in SPPB was significantly associated with primary endpoints (odds ratio, 1.51; 95% confidence interval, 1.12-2.04). Perioperative change in physical function was an independent risk factor for heart failure, hospitalization, or cardiovascular death following TAVI.

Creating 12-lead electrocardiogram waveforms using a three-lead bedside monitor to ensure appropriate monitoring

How do you place the three electrodes to create waveforms for leads I, II, III, aVR, aVL, aVF, and V1-V6?

Effect of PM2.5 for hospitalization of cardiovascular diseases and medical expenses by age group: a nationwide study from the Japanese Registry Of All cardiac and vascular Diseases (JROAD)

Introduction

Although particulate matter with an aerodynamic diameter less than or equal to 2.5 μm (PM2.5) exposure influences cardiovascular events, there is limited knowledge how PM2.5 exposure is associated with cardiovascular hospitalization in Japan.

Purpose

We tested the hypothesis that PM2.5 exposure was related to the number of cardiovascular hospitalizations, hospitalization period, and medical expenses.

Methods

We included 835,405 subjects who were admitted to acute care hospitals in Japan. We classified PM2.5 exposure concentration into quintile groups (from low to high in the order of “PM-1” to “PM-5” group). Multilevel mixed-effects Poisson and linear regression analysis were used to estimate the association of PM2.5 exposure concentration with the cardiovascular hospitalization events, duration and medical expenses. We also analyzed those factors classified by age.

Results

PM-2, 3, 4, 5 group were positively related to the number of cardiovascular hospitalization events compared with PM-1 group (Table 1). PM-3, 4, 5 group were positively associated with a 0.018, 0.029, and 0.029 (all p&lt;0.001) of the difference of log cardiovascular hospitalization period compared with PM-1 group (p for trend &lt;0.001). These groups were also positively associated with a 0.016, 0.023, and 0.021 (all p&lt;0.001) of the difference of log medical expenses compared with PM-1 group (p for trend &lt;0.001). Analyzed by age group, hospitalization duration was longer (p&lt;0.05) and medical expenses was lower (p&lt;0.05) significantly in super-aging group (over 90 years old) than the group under 64 years old (Figure 1).

Conclusions

PM2.5 exposure concentration has harmful effect on not only cardiovascular events but cardiovascular hospitalization period and medical expenses due to big-data in Japan. Medical costs were kept low in comparison with their hospitalization period in subjects over 90 years old.

Figure 1

Funding Acknowledgement

Type of funding source: None

Prognostic value of Mini Nutritional Assessment-Short Form with aortic valve stenosis following transcatheter aortic valve implantation

Aims

Older adults at risk for malnutrition are known to have a high mortality rate. This study aimed to investigate whether the Mini Nutritional Assessment—Short Form (MNA‐SF) could predict midterm mortality in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods and results

We applied the MNA‐SF in 288 patients who had undergone TAVI from January 2016 to June 2019 at the St. Marianna University School of Medicine hospital. Using the MNA‐SF cut‐off value to indicate the risk of malnutrition, patients were divided into two groups, namely, those with an MNA‐SF score ≤11 (impaired MNA‐SF group) and those with an MNA‐SF score ≥12 (maintained MNA‐SF group). We used this value to investigate the association between the MNA‐SF and all‐cause mortality. Overall, 188 (65%) and 100 (35%) patients comprised the impaired MNA‐SF and maintained MNA‐SF groups, respectively, and 41 patients died after TAVI (mean follow‐up duration, 458 ± 315 days). Kaplan–Meier analyses showed that patients in the impaired MNA‐SF group had a significantly higher incidence of all‐cause mortality (hazard ratio 2.67; 95% confidence interval 1.29–6.21; P = 0.01). Multivariate Cox regression analyses showed that the MNA‐SF score was an independent predictor of all‐cause mortality after adjusting for the Society of Thoracic Surgeons risk score, Katz Index, and brain natriuretic peptide test results (hazard ratio 1.14; 95% confidence interval 1.01–1.28; P = 0.04).

Conclusions

The MNA‐SF was useful to screen for the risk of malnutrition in patients with TAVI and in predicting midterm prognoses in patients undergoing TAVI and could predict patient mortality after the procedure.

Prevalence of Unexplained Left Ventricular Hypertrophy by Cardiac Magnetic Resonance Imaging in MESA

Background

Hypertrophic cardiomyopathy is defined as unexplained left ventricular (LV) hypertrophy (wall thickness ≥15 mm) and is prevalent in 0.2% of adults (1:500) in population‐based studies using echocardiography. Cardiac magnetic resonance imaging (MRI) allows for more accurate wall thickness measurement across the entire ventricle than echocardiography. The prevalence of unexplained LV hypertrophy by cardiac MRI is unknown. MESA (Multi‐Ethnic Study of Atherosclerosis) recruited individuals without overt cardiovascular disease 45 to 84 years of age.

Methods and Results

We studied 4972 individuals who underwent measurement of regional LV wall thickness by cardiac MRI as part of the MESA baseline exam. American Heart Association criteria were used to define LV segments. We excluded participants with hypertension, LV dilation (≥95% predicted end‐diastolic volume) or dysfunction (ejection fraction ≤50%), moderate‐to‐severe left‐sided valve lesions by cardiac MRI, severe aortic valve calcification by cardiac computed tomography (aortic valve Agatston calcium score >1200 in women or >2000 in men), obesity (body mass index >35 kg/m²), diabetes mellitus, and current smoking. Sixty‐seven participants (aged 64±10 years, 9% female) had unexplained LV hypertrophy (wall thickness ≥15 mm in at least 2 adjacent LV segments), representing 1.4% (1 in 74) participants, 2.6% of men and 0.2% of women. Prevalence was similar across categories of race/ethnicity. Hypertrophy was focal in 17 (25.4%), intermediate in 44 (65.7%), and diffuse in 5 (7.5%) participants.

Conclusions

The prevalence of unexplained LV hypertrophy in a population‐based cohort using cardiac MRI was 1.4%. This may have implications for the diagnosis of patients with hypertrophic cardiomyopathy and will require further study.

Impact of Board-Certified Cardiologist Characteristics on Risk of In-Hospital Mortality

Background: This study examined the influence of board-certified cardiologist characteristics on the in-hospital mortality of patients with cardiovascular disease.

Methods and Results: Data were collected between 2012 and 2014 from a nationwide database of acute care hospitals in Japan. Overall, there were 1,422,703 patients, of whom 883,746 were analyzed. The primary outcome was all-cause in-hospital mortality. The association between board-certified cardiologist characteristics and in-hospital mortality was estimated using multilevel mixed-effect logistic regression modeling. Median age of cardiologists in a hospital was not related to in-hospital mortality (OR, 1.003; 95% CI: 0.998–1.008, P=0.316), but a greater cardiologist age range was associated with a lower risk of in-hospital mortality (OR, 0.992; 95% CI: 0.988–0.995 per 1-unit increment in age range, P<0.001). Meanwhile, the average years of experience of the board-certified cardiologists in a hospital was not associated with a lower risk of in-hospital mortality (OR, 1.002; 95% CI: 0.996–1.007, P=0.525), but a greater range of years of experience was (OR, 0.986; 95% CI: 0.983–0.990 per 1-unit increment in range of years of experience, P<0.001).

Conclusions: Median board-certified cardiologist age/experience at an institution is not related to in-hospital mortality, but a greater range in age/experience is associated with a lower risk of mortality.

Change in NT-proBNP (N-Terminal Pro-B-Type Natriuretic Peptide) Level and Risk of Dementia in Multi-Ethnic Study of Atherosclerosis (MESA)

Cross-sectionally measured NT-proBNP (N-terminal pro-B-type natriuretic peptide) is related to incident dementia. However, data linking changes in NT-proBNP to risk of future dementia are lacking. We aimed to examine the association of change in NT-proBNP over 3.2 years with incident dementia. We included 4563 participants in MESA (Multi-Ethnic Study of Atherosclerosis) prospective cohort who were free of cardiovascular disease at enrollment, had NT-proBNP level measured at MESA exams 1 (baseline, 2000-2002) and 3 (2004-2005), and had no diagnosis of dementia before exam 3. The association of change in NT-proBNP level between MESA exams 1 through 3 and all-cause hospitalized dementia (by International Classification of Diseases, Ninth Revision, codes) after MESA exam 3 (2004-2005) through 2015 was assessed using competing-risks Cox proportional hazard regression analysis. During 45 522 person-years of follow-up, 223 dementia cases were documented. Increase in log-NT-proBNP from MESA exams 1 through 3 was positively associated with incidence of dementia (multivariable hazard ratio, 1.28 [95% CI, 1.001-1.64]; P=0.049). An increase of at least 25% in NT-proBNP level from MESA exam 1 through 3 was associated with a 55% (P=0.02) increase in the risk of dementia in multivariable analysis. Addition of temporal NT-proBNP change to a model including risk factors and baseline NT-proBNP improved the prediction of dementia (Harrell C statistic from 0.85 to 0.87, P=0.049). Increase in NT-proBNP is independently associated with future all-cause hospitalized dementia and offers a moderately better predictive performance for risk of dementia compared with risk factors and baseline NT-proBNP. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT00005487.

Association between the number of board-certified cardiologists and the risk of in-hospital mortality: a nationwide study involving the Japanese registry of all cardiac and vascular diseases

OBJECTIVES

Although there are 14 097 board-certified cardiologists in Japan, it is unknown whether the number of institutional board-certified cardiologists is related to the prognosis of cardiovascular disease patients.

DESIGN

Cross-sectional analysis.

SETTING

Data were collected from the nationwide database of acute care hospitals in Japan (2371 hospitals) between 2012 and 2013.

PARTICIPANTS

A total of 1 422 703 consecutive patients were initially included in this study, but 518 610 patients were excluded due to age <18 years, missing data or prior hospitalisations; therefore, 896 171 patients comprised the final sample population.

MAIN OUTCOME MEASURES

The primary outcome was in-hospital mortality due to any cause. For the per-hospital analysis, Poisson regression models were used to estimate the association of board-certified cardiologists with in-hospital mortality, adjusted for hospital facilitation. For the per-patient analysis, hierarchical logistic regression models were used to estimate the ORs of the number of institutional board-certified cardiologists, adjusted for patient demographics, diagnoses, therapies and hospital facilities.

RESULTS

The regression model of the per-hospital analysis indicated that the number of board-certified cardiologists was associated with a lower rate ratio of in-hospital mortality (rate ratio, 0.988; 95% CI 0.983 to 0.993; p<0.01). The per-patient analysis indicated that the median age was 73 years and the in-hospital mortality rate was 11.7%. The regression model indicated that the presence of more board-certified cardiologists was associated with a lower risk of in-hospital mortality (OR, 0.980; 95% CI 0.975 to 0.986; p<0.01) after adjustments for hospital facilities, patient characteristics and treatments.

CONCLUSIONS

Among cardiovascular disease patients admitted to acute care hospitals in Japan, the presence of more board-certified cardiologists was associated with a lower risk of in-hospital mortality. These results have implications for national and institutional strategies for determining the required number of board-certified cardiologists.

Abstract WP311: Impact of Physician Volume and Specialty on In-hospital Mortality of Ischemic and Hemorrhagic Stroke -j-aspect Study

Background: The association between physician volume and the death rate for patients who are hospitalized for ischemic and hemorrhagic stroke remains unclear. It is unknown whether a volume threshold for such an association exists. We aimed to analyze the correlation between in-hospital stroke mortality and physician volume considering board certification status.

Methods: For this cross-sectional study, data on patients hospitalized for ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) between 2010 and 2016[MOU1] [KN2] were obtained from the Diagnosis Procedure Combination database in Japan using International Classification of Diseases-10 diagnosis codes. The numbers of stroke care physicians and relevant board-certified physicians were asked. Odd ratios (ORs) of 30 day in-hospital mortality were estimated after adjustment for institutional differences, age, sex, comorbidities, and level of consciousness using generalized mixed logistic regressions.

Findings: In a total of 295,150, 98,657 and 36,1741 patients with ischemic stroke, ICH and SAH, 30 day in-hospital mortality rates were 4.4,16 and 26.6 %. For all types of stroke, the number of stroke care physicians was associated with reduced in-hospital mortality (all p for trend<0·001). The number of board-certified neurosurgeons, stroke physicians, and endovascular surgeons stroke physicians showed clear association with reduced in-hospital mortality of ischemic stroke (volume threshold, OR [95%CI] for three specialties: six, 0·86 [0·79-0·95]; p=0·002, one, 0·79 [0·71-0·87]; p<0·001, three, 0·90 [0·80-1·00]; p=0·046), ICH (six, 0·87 [0·78-0·98]; p=0·019, two, 0·76 [0·60-0·96]; p=0·02, three, 0·82 [0·73-0·93]; p=0·002), and SAH (four, 0·80 [0·71-0·91]; p=0·001, six, 0·72 [0·53-0·98]; p=0·04, two, 0·85 [0·75-0·96]; p=0·01). The number of board-certified neurologists did so only for ischemic stroke (two, 0·88 [0·80-0·97]; p=0·013).

Interpretation: The number of stroke care physicians was associated with reduced in-hospital mortality for all types of stroke. The volume threshold of board-certified physicians depends on specialty and stroke types.

Number of Board-Certified Cardiologists and Acute Myocardial Infarction-Related Mortality in Japan - JROAD and JROAD-DPC Registry Analysis

BACKGROUND

The appropriate number of board-certified cardiologists (BCC) for the treatment of acute myocardial infarction (AMI) has not been thoroughly examined in Japan. This study investigated whether the number of BCC/50 cardiovascular beds affects acute outcome in AMI treatment. Methods and Results: Data on 751 board-certified teaching hospitals and 63,603 patients with AMI were obtained from the Japanese Registry Of All cardiac and vascular Diseases (JROAD) and JROAD Diagnosis Procedure Combination (JROAD-DPC) databases between 1 April 2012 and 31 March 2014. The hospitals were categorized into 3 groups based on the median number of BCC/50 cardiovascular beds: first tertile, 5.0 (IQR, 4.0-5.7); second, 8.3 (IQR, 7.4-9.8); third, 15.3 (IQR, 12.5-22.7), and the patients with AMI admitted to the categorized hospitals were compared (first tertile, 12,002 patients; second, 23,930; third, 27,671). On hierarchical logistic modeling, the adjusted OR for 30-day mortality were 0.86 (95% CI: 0.74-1.00) for the second tertile and 0.75 (95% CI: 0.65-0.88) for the third tertile.

CONCLUSIONS

Patients with AMI admitted to hospitals with a large number of BCC/50 cardiovascular beds had a lower 30-day mortality rate. This tendency was independent of patient and hospital characteristics. This is the first study to provide new information on the association between the number of BCC and in-hospital AMI-related mortality in Japan.

Diabetes mellitus and insulin resistance associate with left ventricular shape and torsion by cardiovascular magnetic resonance imaging in asymptomatic individuals from the multi-ethnic study of atherosclerosis

BACKGROUND

Although diabetes mellitus (DM) and insulin resistance associate with adverse cardiac events, the associations of left ventricular (LV) remodeling and function with compromised glucose metabolism have not been fully evaluated in a general population. We used cardiovascular magnetic resonance (CMR) to evaluate how CMR indices are associated with DM or insulin resistance among participants before developing cardiac events.

METHODS

We studied 1476 participants who were free of clinical cardiovascular disease and who underwent tagged CMR in the Multi-Ethnic Study of Atherosclerosis (MESA). LV shape and longitudinal myocardial shortening and torsion were assessed by CMR. A higher sphericity index represents a more spherical LV shape. Multivariable linear regression was used to evaluate the associations of DM or homeostasis model assessment-estimated insulin resistance (HOMA-IR) with CMR indices.

RESULTS

In multiple linear regression, longitudinal shortening was lower in impaired fasting glucose than normal fasting glucose (NFG) (0.36% lower vs. NFG, p < 0.05); torsion was greater in treated DM (0.24 °/cm greater vs. NFG, p < 0.05) after full adjustments. Among participants without DM, greater log-HOMA-IR was correlated with greater LV mass (3.92 g/index, p < 0.05) and LV mass-to-volume ratio (0.05 /index, p < 0.01), and lower sphericity index (- 1.26/index, p < 0.01). Greater log-HOMA IR was associated with lower longitudinal shortening (- 0.26%/index, p < 0.05) and circumferential shortening (- 0.30%/index, p < 0.05). Torsion was positively correlated with log-HOMA-IR until 1.5 of log-HOMA-IR (0.16 °/cm/index, p = 0.030).), and tended to fall once above 1.5 of log-HOMA-IR (- 0.50 °/cm/index, p = 0.203). The sphericity index was associated negatively with LV mass-to-volume ratio (- 0.02/%, p < 0.001) and torsion (- 0.03°/cm/%, p < 0.001).

CONCLUSIONS

Glucose metabolism disorders are associated with LV concentric remodeling, less spherical shape, and reduced systolic myocardial shortening in the general population. Although torsion is higher in participants who are treated for DM and impaired insulin resistance, myocardial shortening was progressively decreased with higher HOMA-IR and torsion was increased only with less severe insulin resistance.

CLINICAL TRIAL REGISTRATION

Multi-Ethnic Study of Atherosclerosis (MESA): A full list of participating MESA investigators and institutions can be found at http://www.mesa-nhlbi.org/ . Study Start Date: January 1999 ( NCT00005487 ).

Geometry of the left ventricular outflow tract assessed by 3D TEE in patients with aortic stenosis: impact of upper septal hypertrophy on measurements of Doppler-derived left ventricular stroke volume

BACKGROUND

It is unclear how upper septal hypertrophy (USH) affects Doppler-derived left ventricular stroke volume (SV) in patients with AS. The aims of this study were to: (1) validate the accuracy of 3D transesophageal echocardiography (TEE) measurements of the left ventricular outflow tract (LVOT), (2) evaluate the differences in LVOT geometry between AS patients with and without USH, and (3) assess the impact of USH on measurement of SV.

METHODS

In protocol 1, both 3D TEE and multi-detector computed tomography were performed in 20 patients with AS [aortic valve area (AVA) ≤ 1.5 cm²]. Multiplanar reconstruction was used to measure the LVOT short and long diameters in four parts from the tip of the septum to the annulus. In protocol 2, the same 3D TEE measurements were performed in AS patients (AVA ≤ 1.5 cm², n = 129) and controls (n = 30). We also performed 2D and 3D transthoracic echocardiography in all patients.

RESULTS

In protocol 1, excellent correlations of LVOT parameters were found between the two modalities. In protocol 2, the USH group had smaller LVOT short and long diameters than the non-USH group. Although no differences in mean pressure gradient, or SV calculated with the 3D method existed between the two groups, the USH group had greater SV calculated with the Doppler method (73 ± 15 vs. 66 ± 15 ml) and aortic valve area (0.89 ± 0.26 vs. 0.73 ± 0.24 cm²) than the non-USH group.

CONCLUSIONS

3D TEE can provide a precise assessment of the LVOT in AS. USH affects the LVOT geometry in patients with AS, which might lead to inaccurate assessments of disease severity.

Cardiovascular magnetic resonance imaging in heart failure

INTRODUCTION

Heart failure is a complex clinical syndrome resulting from heart structural remodeling and impaired function in ejecting blood; its incidence is increasing markedly worldwide. The observed variations in the structure and function of the heart are attributable to differences in etiology of heart failure. Cardiac magnetic resonance imaging (CMR) can characterize myocardial tissue, assess myocardial viability, and help diagnose specific cardiomyopathies. The emergence of T1 mapping techniques further improves our knowledge and the clinical assessment of myocardial diffuse fibrosis. Physicians, therefore, must identify the variations using CMR to improve patient's symptoms, survival, and quality of life. Area covered: Current reports regarding CMR and the evidence for heart failure diagnosis and therapy as a potential marker of therapeutic response, including low- and high-risk patients, were reviewed. Literature search was performed using PubMed and Google Scholar for literature relevant to CMR, late gadolinium enhancement, T1 mapping, assessment of fibrosis and remodeling, coronary artery, myocardial infarction, heart failure, and its outcomes. Expert commentary: The authors review current evidence and discuss the potential ability of CMR to guide, diagnose, plan risk strategies, and treat patients with heart failure.

Abstract OT2-01-01: Observational study of axilla treatment for breast cancer patients with 1 to 3 positive micrometastases or macrometastases in sentinel lymph nodes

[Background] Axilla surgery in node-positive breast cancer is dramatically changing from axillary lymph node dissection (ALND) to sentinel node biopsy (SNB). From the results of ACOSOG Z0011, IBCSG23-01 and AMAROS trials, adjuvant therapy and regional node irradiation could reduce regional lymph node recurrence for sentinel node-positive breast cancer patients. However, optimal indication of SNB alone remains uncertain. Trial design: To evaluate the outcome of sentinel node-positive breast cancer patients, the Japanese Society for Sentinel Node Navigation Surgery (SNNS) conducted a prospective cohort study in 2013 (UMIN000011782, Jpn J Clin Oncol, p.876-9, 2014). [Eligibility criteria] For eligible patients, SNB was performed or scheduled after 1 January 2012. Then 1 to 3 positive micrometastases or macrometastases in sentinel lymph nodes are confirmed by histological or molecular diagnosis. Primary chemotherapy before or after SNB is also acceptable for registration. [Specific aims] The primary endpoint is the 5-year recurrence rate of regional lymph node in patients treated with SNB alone. The secondary endpoint is the 5-year overall survival rate of this cohort. Patients treated with SNB followed by ALND are also registered simultaneously to compare the prognosis. The propensity score matching (PSM) is used to make the distributions of baseline risk factors comparable. [Statistical method] Based on an estimated recurrence rate of 5% at 5 years among patients treated with SNB alone, 240 patients are needed to give a 80% power to reject the null hypothesis that the recurrence rate is 10% with a one-sided type I error rate of 2.5%. If we consider that some patients will be lost to follow-up or become ineligible, a total of 250 patients will be needed to comprise the sample. [Present accrual] Eight hundred and eighty patients who underwent SNB alone or SNB followed by ALND were registered from 27 participating institutes between 2013 and 2016. Data cleaning is being performed. Patient's background and PSM will be reported.

Citation Format: Imoto S, Saito Oba M, Masuda N, Nagashima T, Wada N, Takashima T, Kitada M, Kawada M, Hayashida T, Taguchi T, Aihara T, Miura D, Toh U, Yoshida M, Sugae S, Yoneyama K, Matsumoto H, Jinno H, Sakamoto J. Observational study of axilla treatment for breast cancer patients with 1 to 3 positive micrometastases or macrometastases in sentinel lymph nodes [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-01-01.

Minimally invasive percutaneous transluminal renal artery stenting

BACKGROUND

Minimally invasive percutaneous transluminal renal artery stenting (MIPTRS) is a method that prevents complications to the greatest extent possible. The present study aimed to investigate the safety and efficacy of MIPTRS performed in cases of renal artery stenosis with an estimated glomerular filtration rate (eGFR)≤45mL/min.

METHODS

Cases of patients who underwent MIPTRS at our hospital between December 2010 and June 2015 in whom eGFR was ≤45mL/min were retrospectively analysed. MIPTRS was performed as follows: 1) using a 4Fr sheathless guiding catheter in a trans-radial approach and 2) using a guiding catheter non-touch technique. The amount of contrast agent used was maintained at ≤10mL with 3) carbon dioxide enhancement and 4) intravascular ultrasound guide stenting, and 5) a distal protection device was used.

RESULTS

MIPTRS was performed in 22 patients (32 lesions). The pre-MIPTRS creatinine level and eGFR were 2.01±0.88mg/dL and 29.2±9.0mL/min/1.73m², respectively. On postoperative day 2, they were 1.78±0.73mg/dL and 35.1±12.3mL/min/1.73m²; at 1month after the procedure, they were 1.80±0.74mg/dL and 33.3±12.3mL/min/1.73m². Creatinine level did not change significantly, but eGFR was significantly elevated after versus before the procedure, both 2days later (p<0.01) and 1month later (p<0.05).

CONCLUSION

The results of this study demonstrated the usefulness of MIPTRS for protecting renal function. This method can be safely used in patients with decreased renal function.

Left Ventricular Hypertrophy and Remodeling and Risk of Cognitive Impairment and Dementia: MESA (Multi-Ethnic Study of Atherosclerosis)

Limited information exists on the longitudinal association between the left ventricular (LV) structure and function and future cognitive impairment and dementia in a large population without clinically recognized cardiovascular disease at baseline. The aim of the present study was to investigate the association between cardiac structure and function and risk of dementia and cognitive impairment in the MESA (Multi-Ethnic Study of Atherosclerosis) cohort. Measures of LV structure and function were determined using magnetic resonance imaging at baseline in 4999 participants free of clinically diagnosed cardiovascular disease and dementia. Probable incident clinical dementia was ascertained from hospitalization discharge records. Cognitive function was evaluated using tests addressing global cognitive function, processing speed, and memory. Associations of measures of LV structure and function with the incidence of clinically diagnosed dementia and cognitive performance were evaluated using Cox proportional hazard regression models adjusted for demographics, cardiovascular risk factors, and cardiovascular events. During a median follow-up of 12 years, 130 probable incident dementia cases were documented. Higher LV mass index (hazard ratio, 1.01; 95% confidence interval, 1.00-1.02) and LV mass-to-volume ratio (hazard ratio, 2.37; 95% confidence interval, 1.25-4.43) were independently associated with incident dementia and impaired cognitive function. Measures of LV function were not associated with risk of dementia or cognitive impairment. In conclusion, in a multiethnic cohort of participants without clinically detected cardiovascular disease and dementia at baseline, LV hypertrophy and concentric remodeling were independently associated with incident dementia and cognitive impairment.

Association of Aortic Root Dilation from Early Adulthood to Middle Age with Cardiac Structure and Function: The CARDIA Study

BACKGROUND

The human aorta dilates with advancing age. However, the association between progressive aortic dilation with aging and cardiac remodeling has not been established in studies of community-dwelling adults. The aim of this study was to test the hypothesis that there would be a relationship between aortic size increase over the early adult life span with left ventricular (LV) structural remodeling and subclinical LV dysfunction in middle age, even in the absence of overt cardiovascular and valvular disease.

METHODS

Included were Coronary Artery Risk Development in Young Adults study participants (N = 2,933) aged 23 to 35 years with available transthoracic echocardiographic measurements during 20 years of follow-up. Multivariate linear regression models assessed sex-specific associations between 20-year change in aortic root diameter with LV structure and function.

RESULTS

Larger aortic root diameter at 20-year follow-up was associated with greater LV mass (2.77 vs 2.18 g/mm in men and women, respectively, P < .001). In longitudinal analyses, increase in aortic root diameter over 20-year follow-up was associated with a greater 20-year increase in LV mass and ratio of LV mass to LV end-diastolic volume ratio in both sexes. In women but not in men, increased aortic root diameter over 20 years was associated with increased left atrial dimension, impaired E/E', and impaired early diastolic longitudinal and circumferential strain rates assessed by speckle-tracking echocardiography.

CONCLUSIONS

Progressive increase in aortic root diameter from early adulthood to middle age was associated with increased LV mass and LV concentric remodeling in both sexes and impaired diastolic function predominantly in women.

Electrocardiographic Strain Pattern Is Associated With Left Ventricular Concentric Remodeling, Scar, and Mortality Over 10 Years: The Multi-Ethnic Study of Atherosclerosis

Background

Both ECG strain pattern and QRS measured left ventricular (LV) hypertrophy criteria are associated with LV hypertrophy and have been used for risk stratification. However, the independent predictive value of ECG strain in apparently healthy individuals in predicting mortality and adverse cardiovascular events is unclear.

Methods and Results

MESA (Multi‐Ethnic Study of Atherosclerosis) is a multicenter, prospective cohort of 6441 participants (mean age, 62 years; 54% women). In 2847 of these participants, cardiac magnetic resonance imaging was repeated ≈10 years later (Year‐10). At Year‐10, 1759 participants underwent cardiac magnetic resonance imaging with gadolinium to detect myocardial scar. During a median follow‐up of 11.7 years, ECG strain (n=168, 2.6%) was significantly associated with all‐cause death (adjusted hazard ratio, 1.33; 95% confidence interval, 1.01–1.77; P=0.045), heart failure (2.62; 1.73–3.97; P<0.001), myocardial infarction (1.86; 1.09–3.18; P=0.024), and incident cardiovascular disease (1.45; 1.06–2.00; P=0.022). ECG strain was also associated with an increase in LV mass (β=9.29 g; P<0.001) and LV mass‐to‐volume ratio (β=0.07 g/mL; P=0.007) and a decline in LV ejection fraction (β=−3.30%; P<0.001). Moreover, ECG strain either at baseline and Year‐10 was associated with LV scar (odds ratio, 4.93 and 5.22; P=0.002 and <0.001, respectively), whereas these associations were not observed in ECG LV hypertrophy.

Conclusions

ECG strain is independently associated with all‐cause mortality, adverse cardiovascular events, development of LV concentric remodeling and systolic dysfunction, and myocardial scar over 10 years in multiethnic participants without past cardiovascular disease. ECG strain may be an early marker of LV structural remodeling that contributes to development of adverse cardiovascular events.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00005487.

Cardiovascular magnetic resonance in an adult human population: serial observations from the multi-ethnic study of atherosclerosis

The Multi-Ethnic Study of Atherosclerosis (MESA) is the first large-scale multi-ethnic population study in the U.S. to use advanced cardiovascular magnetic resonance (CMR) imaging. MESA participants were free of cardiovascular disease at baseline between 2000 and 2002, and were followed up between 2009 and 2011 with repeated CMR examinations as part of MESA. CMR allows the clinician to visualize and accurately quantify volume and dimensions of all four cardiac chambers; measure systolic and diastolic ventricular function; assess myocardial fibrosis; assess vessel lumen size, vessel wall morphology, and vessel stiffness. CMR has a number of advantages over other imaging modalities such as echocardiography, computed tomography, and invasive angiography, and has been proposed as a diagnostic strategy for high-risk populations. MESA has been extensively evaluating CMR imaging biomarkers, as markers of subclinical disease, in the last 15 years for low-risk populations. On a more practical level, some of the imaging biomarkers developed and studied are translatable to at-risk populations. In this review, we discuss the progression of subclinical cardiovascular disease and the mechanisms responsible for the transition to symptomatic clinical outcomes based on our findings from MESA.

Impaired left atrial function predicts inappropriate shocks in primary prevention implantable cardioverter-defibrillator candidates

INTRODUCTION

Inappropriate implantable cardioverter-defibrillator (ICD) shocks, commonly caused by atrial fibrillation (AF), are associated with an increased mortality. Because impaired left atrial (LA) function predicts development of AF, we hypothesized that impaired LA function predicts inappropriate shocks beyond a history of AF.

METHODS AND RESULTS

We prospectively analyzed the association between LA function and incident inappropriate shocks in primary prevention ICD candidates. In the Prospective Observational Study of ICD (PROSE-ICD), we assessed LA function using tissue-tracking cardiac magnetic resonance (CMR) prior to ICD implantation. A total of 162 patients (113 males, age 56 ± 15 years) were included. During the mean follow-up of 4.0 ± 2.9 years, 26 patients (16%) experienced inappropriate shocks due to AF (n = 19; 73%), supraventricular tachycardia (n = 5; 19%), and abnormal sensing (n = 2; 8%). In univariable analyses, inappropriate shocks were associated with AF history prior to ICD implantation, age below 70 years, QRS duration less than 120 milliseconds, larger LA minimum volume, lower LA stroke volume, lower LA emptying fraction, impaired LA maximum and preatrial contraction strains (S_max and S_preA ), and impaired LA strain rate during left ventricular systole and atrial contraction (SR_s and SR_a ). In multivariable analysis, impaired S_max (hazard ratio [HR]: 0.96, P = 0.044), S_preA (HR: 0.94, P = 0.030), and SR_a (HR: 0.25, P < 0.001) were independently associated with inappropriate shocks. The receiver-operating characteristics curve showed that SR_a improved the predictive value beyond the patient demographics including AF history (P = 0.033).

CONCLUSION

Impaired LA function assessed by tissue-tracking CMR is an independent predictor of inappropriate shocks in primary prevention ICD candidates beyond AF history.

Association of Aortic Stiffness With Left Ventricular Remodeling and Reduced Left Ventricular Function Measured by Magnetic Resonance Imaging: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

This study sought to assess cross-sectional associations of aortic stiffness assessed by magnetic resonance imaging with left ventricular (LV) remodeling and myocardial deformation in the Multi-Ethnic Study of Atherosclerosis (MESA).

METHODS AND RESULTS

Aortic arch pulse wave velocity (PWV) was measured with phase contrast cine magnetic resonance imaging. LV circumferential strain (Ecc), torsion, and early diastolic strain rate were determined by tagged magnetic resonance imaging. Multivariable linear regression models were used to adjust for demographics and cardiovascular risk factors. Of 2093 participants, multivariable linear regression models demonstrated that higher arch PWV was associated with higher LV mass index (B=0.53 per 1 SD increase for log-transformed PWV, P<0.05) and LV mass to volume ratio (B=0.015, P<0.01), impaired LV ejection fraction (LVEF; B=-0.84; P<0.001), Ecc (B=0.55; P<0.001), torsion (B=-0.11; P<0.001), and early diastolic strain rate (B=-0.003; P<0.05). In sex stratified analysis, higher arch PWV was associated with higher MVR (B=0.02; P<0.05), impaired Ecc (B=0.60; P<0.001), and LVEF (B=-0.45; P<0.05), but with maintained torsion in women. Higher PWV was associated with impaired Ecc (B=0.49; P<0.001) and LVEF (B=-1.21; P<0.001), with lower torsion (B=-0.17; P<0.001) in men.

CONCLUSIONS

Higher arch PWV is associated with LV remodeling, and reduced LV systolic and diastolic function in a large multiethnic population. Greater aortic arch stiffness is associated with concentric LV remodeling and relatively preserved LVEF with maintained torsion in women, whereas greater aortic arch stiffness is associated with greater LV dysfunction demonstrated as impaired Ecc, torsion, and LVEF, with less concentric LV remodeling in men.

Angioscopic and optical coherence tomographic evaluation of neointimal coverage: 9 months after expandable polyterafluoroethylene covered stent implantation

An expandable polytetrafluoroethylene (ePTFE) covered stent is generally employed to seal coronary artery perforation. The frequency of ePTFE covered stent use is relatively low; thus, only a handful of studies have reported neointimal coverage and endothelialization inside the deployed ePTFE and clinical time course after ePTFE implantation. This case report presents a 78-year-old man treated with an ePTFE covered stent when he suffered from coronary artery perforation after the implantation of two everolimus eluting stents in the left anterior descending artery. Follow-up coronary angiography 9 months after ePTFE covered stent implantation depicted favorable stent patency. Optical coherence tomography showed thin and uneven stent strut coverage at the culprit. Angioscopy also depicted partial white-coated coverage and stent strut exposure. The outcome of this case suggested that long-term dual antiplatelet therapy should be prescribed for preventing thrombosis after ePTFE covered stent implantation.

Left ventricular shape predicts different types of cardiovascular events in the general population

OBJECTIVE

To investigate whether sphericity volume index (SVI), an indicator of left ventricular (LV) remodelling, predicts incident cardiovascular events (coronary heart disease, CHD; all cardiovascular disease, CVD; heart failure, HF; atrial fibrillation, AF) over 10 years of follow-up in a multiethnic population (Multi-Ethnic Study of Atherosclerosis).

METHODS

5004 participants free of known CVD had magnetic resonance imaging (MRI) in 2000-2002. Cine images were analysed to compute, [Formula: see text] equivalent to LV volume/volume of sphere with length of LV as the diameter. The highest (greatest sphericity) and lowest (lowest sphericity) quintiles of SVI were compared against the reference group (2-4 quintiles combined). Risk-factor adjusted hazard's ratio (HR) from Cox regression assessed the predictive performance of SVI at end-diastole (ED) and end-systole (ES) to predict incident outcomes over 10 years in retrospective interpretation of prospective data.

RESULTS

At baseline, participants were aged 61±10 years; 52% men and 39%/13%/26%/22% Cauc/Chinese/Afr-Amer/Hispanic. Low sphericity was associated with higher Framingham CVD risk, greater coronary calcium score and higher N-terminal pro-brain natriuretic peptide (NT-proBNP); while increased sphericity was associated with higher NT-proBNP and lower ejection fraction. Low sphericity predicted incident CHD (HR: 1.48, 1.55-2.59 at ED) and CVD (HR: 1.82, 1.47-2.27 at ED). However, both low (HR: 1.81, 1.20-2.73 at ES) and high (HR: 2.21, 1.41-3.46 at ES) sphericity predicted incident HF. High sphericity also predicted AF.

CONCLUSIONS

In a multiethnic population free of CVD at baseline, lowest sphericity was a predictor of incident CHD, CVD and HF over a 10-year follow-up period. Extreme sphericity was a strong predictor of incident HF and AF. SVI improved risk prediction models beyond established risk factors only for HF, but not for all CVD or CHD.

Influence of aortic valve leaflet calcification on dynamic aortic valve motion assessed by cardiac computed tomography

BACKGROUND

Computed tomography is the best noninvasive imaging modality for evaluating valve leaflet calcification.

OBJECTIVE

To evaluate the association of aortic valve leaflet calcification with instantaneous valve opening and closing using dynamic multidetector computed tomography (MDCT).

METHODS

We retrospectively evaluated 58 consecutive patients who underwent dynamic MDCT imaging. Aortic valve calcification (AVC) was quantified using the Agatston method. The aortic valve area (AVA) tracking curves were derived by planimetry during the cardiac cycle using all 20 phases (5% reconstruction). da/dt in cm²/s was calculated as the rate of change of AVA during opening (positive) or closing (negative). Patients were divided into 3 three groups according to Agatston score quartile: no AVC (Q2, Score 0, n = 18), mild AVC (Q3, Score 1-2254, n = 24), and severe AVC (Q4 Score >2254, n = 14).

RESULTS

In multivariable linear regression, compared to the non AVC group, the mild and severe AVC groups had lower maximum AVA (by -1.71 cm² and -2.25 cm², respectively), lower peak positive da/dt (by -21.88 cm²/s and -26.65 cm²/s, respectively), and higher peak negative da/dt (by 13.78 cm²/s and 18.11 cm²/s, respectively) (p < 0.05 for all comparisons).

CONCLUSIONS

AVA and its opening and closing were influenced by leaflet calcification. The present study demonstrates the ability of dynamic MDCT imaging to assess quantitative aortic valve motion in a clinical setting.

Aortic annulus displacement assessed by contrast left ventriculography during invasive coronary angiography as a predictor of adverse events

BACKGROUND

We propose the use of aortic annulus displacement (AAD) detected on contrast left ventriculography (LVG) during invasive coronary angiography as a marker of left ventricular (LV) long-axis shortening. In the present study, we aimed to investigate whether AAD is associated with adverse events in patients who underwent coronary angiography because of suspected coronary artery disease.

METHODS

In this retrospective study, we evaluated the medical records of 998 consecutive patients who underwent invasive coronary angiography and LVG. LV lengths were measured from the apex to the aortic valve insertion by using LVG images. AAD (%) was calculated as [(LV end-diastolic length-LV end-systolic length)/LV end-diastolic length]×100.

RESULTS

The participants' median age was 67 years. Ninety-six adverse events (composite events; all-cause death, 39; congestive heart failure, 21; late revascularization, 34; and myocardial infarction, 2) were observed during a median follow-up period of 3.1 years. In multivariate Cox regression analysis, adverse events were associated with lower AAD (hazard ratio, 0.703; p=0.002), after adjusting for traditional risk factors and coronary artery stenosis. The area under the curve of AAD for predicting adverse events was greater than that of LV ejection fraction (0.656 vs. 0.541, p<0.05).

CONCLUSIONS

AAD was superior to LV ejection fraction as a predictor of adverse events in patients with and without coronary arterial stenosis. AAD may be the optimal method for assessing longitudinal LV systolic function in the catheter laboratory.

Reduced long axis strain is associated with heart failure and cardiovascular events in the multi-ethnic study of Atherosclerosis

PURPOSE

To propose long axis strain (LAS), a novel index of global left ventricle (LV) function, as a sensitive and powerful predictor of hard cardiovascular events and heart failure in the Multi-Ethnic Study of Atherosclerosis (MESA).

MATERIALS AND METHODS

Strain is an index of relative myocardial deformation, and enables normalization for differences in heart size. Measurement of strain conventionally requires dedicated software and protocols for image acquisition. LAS, however, can be analyzed using a caliper tool from conventional LV long axis magnetic resonance imaging (MRI) cine loops, reflecting the average myocardial contraction in the longitudinal direction. In all, 1651 participants (53% men) of the MESA study, without a history of myocardial infarction or heart failure, were assessed using conventional cine MR images. LV lengths were assessed at end-diastole (EDL ) and end-systole (ESL ), and LAS was calculated as 100*(EDL -ESL )/EDL . Participants were followed for 6.8 ± 1.8 years for a composite endpoint of congestive heart failure or hard cardiovascular events, and the predictive ability of LAS was tested, unadjusted and adjusted for established cardiovascular risk factors.

RESULTS

A total of 114 events were observed. Mean LAS was 11.7 ± 2.5% and 10.0 ± 2.7% in participants without and with events, respectively (P < 0.001). Increased LAS reduced the hazard ratio to 0.75 for univariate, and 0.88 for multivariate assessments, respectively (both P < 0.001).

CONCLUSION

Assessment of long axis LV deformation by LAS is feasible and reproducible. Moreover, LAS predicts hard cardiovascular events and congestive heart failure in a multi-ethnic population without overt cardiovascular disease at inclusion. J. Magn. Reson. Imaging 2016;44:178-185.

Abstract P022: Association of Longitudinal Change in Kidney Function with Left Ventricular Structure and Function as Measured by Cardiac MRI: The Multi-Ethnic Study of Atherosclerosis (MESA)

Background: This study examines the association of change in estimated glomerular filtration rate (eGFR) with change in left ventricular (LV) structure and function over 10 years of follow-up.

Method: MESA participants with cardiac magnetic resonance imaging (CMR) measures and eGFR measured at both baseline (2000-2002, year-0) and the 10 year follow-up (2010-2012, year-10) exam were studied. Participants with cardiovascular disease (CVD) were excluded. LV mass and volume indexed to body surface area, LV ejection fraction (LVEF), and LV mass volume ratio (MVR) were determined by CMR. We stratified participants by the presence of eGFR < 60 ml/min/m2 at baseline and at year 10 into 4 groups; eGFR ≥60 at both year-0 and year-10 (reference), ≥60 at year-0 and <60 at year-10, <60 at year-0 and ≥60 at year-10, and <60 at both year-0 and 10. Multiple linear regression models were used to evaluate the association between eGFR groups and change in LV parameters (year-10 - year-0) after adjusting for the demographics, baseline CVD risk factors, change in risk factors, and baseline LV parameters.

Results: 2,722 participants (age 59 ± 9 years, 53% women, 42% White, 13% Chinese, 25% African American, 20% Hispanic) were included. Compared to the reference group, the group with eGFR ≥60 at year-0 and <60 at year-10 and the group with eGFR <60 at both year-0 and 10 group showed increasing MVR during 10 year follow-up. No difference in longitudinal change in LV mass or LVEF by eGFR groups were noted (Table).

Conclusion: In this multi-ethnic cohort of adults without clinical CVD, reduced eGFR at baseline or during follow-up was associated with the development of concentric remodeling represented by increased MVR.

Association between inflammatory biomarkers and thin-cap fibroatheroma detected by optical coherence tomography in patients with coronary heart disease

INTRODUCTION

The relationship between plaque morphology detected by optical coherence tomography (OCT) and inflammatory biomarkers is not well known.

MATERIAL AND METHODS

This study included 47 patients with ischemic heart disease (22 patients with acute coronary syndrome and 25 patients with effort angina pectoris) who underwent percutaneous coronary intervention (PCI). Before PCI, peripheral blood levels of the inflammatory biomarkers high-sensitivity C-reactive protein (hs-CRP) and interleukin-6 (IL-6) were measured. The OCT can detect thin-cap fibroatheroma (TCFA), a lesion with high potential for adverse cardiac events. We investigated the relationships between TCFAs in culprit lesions detected by OCT and the peripheral blood levels of these biomarkers.

RESULTS

We observed 12 lesions detected as TCFAs. The natural logs of hs-CRP and IL-6 levels in the TCFA group were higher than those in the non-TCFA group (hs-CRP 0.87 (-0.96 to 0.87) vs. -0.47 (-0.92 to 0.30) mg/l, p = 0.027; and IL-6 1.63 (0.63-3.23) vs. 0.53 (-0.21 to 1.05) pg/dl, p = 0.005, respectively). In multivariate logistic regression analysis, log IL-6 was an independent predictor for TCFA detected by OCT (log IL-6, 0.970 pg/dl, p = 0.023). Receiver operating characteristic curve analysis confirmed that IL-6, compared to hs-CRP, has a higher area under the curve for predicting TCFA (0.783 vs. 0.715, respectively).

CONCLUSIONS

Peripheral blood levels of both hs-CRP and IL-6 were associated with TCFAs, as detected by OCT. Moreover, IL-6 has a higher potential than hs-CRP for predicting TCFA.