Mankad, Rekha

Abstract 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 <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 (<65 years) and sex categories. We also categorized ideal cardiovascular health as ≥4 metrics [non-smoker, body mass index <25 kg/m2, and not having of elevated blood pressure (≥130/80 mmHg), LDL cholesterol (>100 mg/dL), or fasting blood glucose (>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%) <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 <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<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 <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

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.

ObjectiveValvular 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.MethodsA 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.ResultsSixty‐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).ConclusionsThe 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.

BackgroundAcute myocardial infarctions (AMI) continue to be common in the United States. Mechanical complications of AMI can lead to cardiogenic shock (CS) and death. The aim of this study was to review the cases of papillary muscle ruptures in the setting of myocardial infarctions at a tertiary care center, with a focus on the clinical presentation and echocardiographic diagnosis.MethodsThis was a retrospective study from January 1, 2000 through December 31, 2014. In all, 22 patients with AMI and papillary muscle rupture (AMI‐PMR) who had surgical intervention were identified.ResultsThe average age was 70 (±11) with 16 (73%) males. Six patients presented with ST‐elevation myocardial infarctions (STEMI) and all underwent emergent revascularization with primary percutaneous coronary intervention (PCI) prior to the diagnosis of AMI‐PMR. The other 16 patients presented with a non‐STEMI. In total, 17 (77%) of the 22 patients were diagnosed with an AMI‐PMR within 7 days from their onset of symptoms. In all, 12 patients (55%) had anterolateral papillary muscle ruptures (ALPMR), and the other 10 had posteromedial papillary muscle ruptures (PMPMR). Ruptures were complete in 10 patients (45%). Patients presented with pulmonary edema early (<7 days) more commonly than late (>14 days). Transthoracic echocardiography was able to demonstrate severe mitral regurgitation in 86% and a definitive or suggestive diagnosis in 93%. All 22 patients survived to operative management, and the overall in‐hospital mortality rate was 9%.ConclusionIn conclusion, ischemic papillary muscle ruptures continue to occur, but with prompt diagnosis by echocardiography and rapid surgical management, the mortality rate continues to decline.

Hypereosinophilic syndrome (HES) is a heterogeneous group of conditions that is defined at its core by hypereosinophilia (HE) (blood eosinophil count of >1.5×10 9 /L) and organ damage directly attributable to the HE. Cardiac dysfunction occurs frequently in all forms of HES and is a major cause of morbidity and mortality. Once a significantly elevated eosinophil count is identified, it must be confirmed on repeat testing and the aetiology for the HE must be rigorously sought out with a focus on identifying whether organ dysfunction is occurring. Echocardiography is routinely performed to assess for cardiac involvement, looking for evidence of left ventricular and/or right ventricular apical obliteration or thrombi or a restrictive cardiomyopathy. Cardiac magnetic resonance imaging and CT are often useful adjuncts to establish the diagnosis but endomyocardial biopsy remains the gold standard. To decrease the degree of eosinophilia, treatment can include corticosteroids and/or imatinib based on the aetiology. Anticoagulation, standard heart failure therapy for a restrictive cardiomyopathy and finally cardiac transplantation may be indicated in the treatment algorithm.

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.

Background: Cardiovascular (CV) disease is the leading cause of death in U.S. women. Although women are becoming more aware of CV disease, there remains a dichotomy between awareness and perceived risk. We sought to characterize this dichotomy in women attracted to a CV health–screening event, in order to improve strategies to reduce CV risk. Methods: During CV health events held in Rochester, Minnesota, from 2007 through 2011, 294 women underwent screening for blood chemistry, body mass index, and blood pressure. Participants also completed surveys about knowledge of CV disease, risk factors, and perceived risk. Risk level was determined from the 2011 American Heart Association Effectiveness-Based Guidelines for Women. Results: Among participants (age, mean [standard deviation], 53 [15.3] years; white, 98%), 99% were aware that CV disease is the leading cause of death in women. Almost half (47%) perceived themselves to be at personal risk, although 65% were determined to be “at risk” and 12% to be at “high risk” according to guidelines, while 22% were uncategorized. Of the 228 participants “at risk” or “high risk,” 48% and 21%, respectively, did not perceive themselves to be at any risk. Conclusions : Women attracted to CV health events were aware that CV disease is the leading cause of death for women. However, the magnitude of awareness did not directly translate into perception or understanding of actual personal risk. To decrease the rate of CV disease in women, continued efforts are needed to personalize the importance of, and the methods for reducing, CV risk factors.