Greene, Eddie L.

Introduction: Although the prevalence of atrial fibrillation (AF) is higher in men than in women, the onset of AF appears to diminish the survival advantage in women. The pathophysiologic factors underlying survival outcome in AF are not well understood. Methods: A cohort of 3480 Olmsted County, Minnesota residents (mean age 72.8±14 years, 51.8% female) with incident AF who underwent transthoracic echocardiography within 30 days of AF diagnosis [median (IQR) 1, 1-6 days] were retrospectively studied. We examined the association of clinical parameters and survival according to gender. Kaplan-Meier and Cox proportional hazards models were used to compare overall survival in males and females. Results: Females were older and slimmer than males and more frequently had hypertension, prior stroke, and had higher CHA 2 DS 2 vasc score, pulse pressure and effective arterial elastance. Women also had smaller LV end diastolic dimension with higher LV ejection fraction, LA volume index, E/e prime ratio, and PASP (43.6±13.8 vs 39.1±13.3; <.001). During a mean follow-up of 7.4±6.2 years (median 6.6 years), 2569 patients died. Women had a lower 5-year survival compared to men. The probability of 1- and 5-year survival rates for women vs men were 80.2% vs 84.1% at 1 year and 54.4% vs 63.7% at 5 years (log-rank P <.001). In multivariable Cox regression analysis, after accounting for potential confounders, the independent predictors of mortality were age (HR 1.07 [95% CI 1.06-1.08]), PASP (per 5 unit increment) (HR 1.11 [95% CI 1.09-1.12]), effective arterial elastance (HR 1.06 [95% CI 1.01-1.12]), previous heart failure (HR 1.34 [95% CI 1.20-1.49]), diabetes (HR 1.33 [95% CI 1.20-1.48]), prior stroke (HR 1.26 [95% CI 1.13-1.41]), smoking (HR 1.13 [95% CI 1.06-1.20]), chronic lung disease (HR 1.32 [95% CI 1.20-1.45]), peripheral arterial disease (HR, 1.32 [95% CI 1.18-1.48]), and chronic kidney disease (HR, 1.52 [95% CI 1.38-1.69]). Conclusions: In a community-based cohort of patients with incident AF, markers of arterial stiffness and diastolic dysfunction were more prevalent in women compared to men and were strongly predictive of mortality. Our findings suggest that vascular stiffness may underlie the increased risk of mortality observed in women after a new diagnosis of AF.

Background The optimal strategy for remission-maintenance therapy in patients with myeloperoxidase-ANCA (MPO-ANCA)–associated vasculitis is not established. Defining parameters to guide maintenance therapy is required. Methods This was a retrospective cohort study of all patients with MPO-ANCA–associated vasculitis (microscopic with polyangiitis and granulomatosis with polyangiitis) and GN followed at the Mayo Clinic between 1996 and 2015. Relapse rate, MPO-ANCA status, and remission-maintenance therapies were reviewed. Logistic regression models, Kaplan–Meier method, and Cox proportional hazards regression models were applied. Results We analyzed 159 patients with active MPO-ANCA–associated vasculitis with GN. Sixty-six (42%) patients had at least one relapse, and 52 (33%) relapsed before 60 months. Patients with MPO-ANCA who became persistently negative did not relapse (hazard ratio [HR], 0.03; 95% confidence interval [95% CI], 0.002 to 0.431; P =0.01). The reappearance of MPO-ANCA was associated with a higher risk of relapse (HR, 1.91; 95% CI, 1.109 to 3.293; P =0.02). Immunosuppression was withdrawn in 80 (50%) patients, and this was less likely in those who received cyclophosphamide for remission induction or in patients with persistently positive MPO-ANCA (odds ratio [OR], 0.44; 95% CI, 0.228 to 0.861; P =0.02 and OR, 0.42; 95% CI, 0.213 to 0.820; P =0.01, respectively). Relapse frequency was not different between patients with persistently positive MPO-ANCA and patients with MPO-ANCA reappearance (44% versus 39%, P =0.49), irrespective of remission-maintenance treatment. Ear, nose, and throat involvement (OR, 6.10; 95% CI, 1.280 to 29.010; P =0.02) and MPO-ANCA reappearance (OR, 9.25; 95% CI, 3.126 to 27.361; P <0.001) were independently associated with relapse after treatment withdrawal. Conclusions Patients persistently MPO-ANCA negative are at low risk for relapse even without remission-maintenance therapy. Persistence or subsequent reappearance of MPO-ANCA is associated with a higher risk of relapse. Podcast This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast.aspx?p=CJASN&e=2023_01_10_CJN06460622.mp3

Introduction: Segmental arterial mediolysis (SAM) is nonatherosclerotic and noninflammatory arteriopathy. It commonly affects the abdominal vasculature. There is uncertainty about its presentation, radiological findings, prognosis and management. Hypothesis: The goal of this study is to describe the clinical course and evaluate risk factors for disease progression. Method: Retrospective review of all cases diagnosed with SAM at the Mayo clinic between 2001 and 2014. Medical records were reviewed for demographics, risk factors, laboratory, imaging findings and treatment options at presentation and during follow-up visits. A non-parametric Wilcoxon-rank-sum test and the Chi-Square test were used. Results: Out of 247 reviewed cases, 114 patients were confirmed with SAM and included in the analysis. (69%) were male and a majority (84%) had no other connective tissue disorder. Mean age was (52) years old. Pre-existing hypertension was identified in (48%), hyperlipidemia (31%), migraine (11%) and smoking (32%). The most common symptoms at presentation were abdominal pain (70%), flank pain (21%), back pain (8%) and chest pain (5%). Only (30%) of patients had recurrent symptoms and most (89%) had negative inflammatory markers. On angiography the following arteries were commonly affected: renal (51%), celiac (43%), superior mesenteric (49%), and iliac (18%). At presentation (85%) of patients were found to have mesenteric arterial dissection; (45%) aneurysms; (14%) wind or wall thickening; (21%) occlusion; and (38%) with evidence of end organ ischemia or infarct. 82 patients were followed up with a CT angiogram for an average of 19 months, 17 (20.73%) had evidence of disease progression. (22%) required revascularization. Aspirin (47%) was the most common treatment used followed by anticoagulation (38%), beta blocker (35%) and ACEI/ARB (29%). Risk factors for disease progression are being male (P<0.0173), Hypertension (P<0.0128), hyperlipidemia (P<= 0.0044). The use of antiplatelets and ACEI/ARB was not associated with disease stability. Conclusion: SAM is an arteriopathy that affects the mesenteric arteries in middle age men. Conservative management with control of risk factors and close follow up are preferred approach.

Objective To investigate the association of mitral regurgitation (MR) on thromboembolic risk of patients with non-valvular atrial fibrillation (NVAF) undergoing transoesophageal echocardiography (TEE)-guided cardioversion. Methods Data for consecutive patients who underwent TEE-guided cardioversion for NVAF between 2000 and 2012 were analysed. MR severity was assessed by Doppler echocardiography and classified as ≤mild, moderate or severe. Left atrial appendage emptying velocities were averaged for five consecutive cycles. Multivariable regression models were used to identify independent predictors of left atrial appendage thrombus (LAAT) and stroke. Results 2950 patients (age, 69.3±12.2 years, 67% men) were analysed. 2173 (73.7%) had ≤mild MR; 631 (21.4%), moderate MR; and 146 (4.9%), severe MR. Patients with moderate (age, 72.4±10.7 years) and severe (age, 72.8±12.1 years) MR were older than those with ≤mild MR (age, 68.2±12.5 years). The prevalence of LAAT was 1.5% (n=43). CHA 2 DS 2 -VASc scores (≤mild MR, 3.0±1.6; moderate MR, 3.5±1.5; severe MR, 3.9±1.5; p<0.001) and heart failure frequency (≤mild MR, 38.4%; moderate MR, 48.0%; severe MR, 69.2%; p<0.001) were increasingly higher with greater MR severity. Multivariable logistic regression analysis showed no association of moderate MR (OR 0.77, 95% CI 0.38 to 1.56) or severe MR (OR 0.55, 95% CI 0.21 to 1.49) with LAAT. During a mean follow-up of 7.3±5.1 years (median 7.5, IQR, 2.7–10.9), 216 patients had an ischaemic stroke. Adjusted Cox regression analysis showed no significant association of moderate MR (HR 1.22, 95% CI 0.88 to 1.68) or severe MR (HR 0.73, 95% CI 0.31 to 1.46) with stroke. Conclusions Among patients with NVAF, the presence or severity of MR was not associated with a decreased risk of LAAT or stroke.

Objective Previous studies have postulated a causal role of patent foramen ovale (PFO) in the aetiology of embolic stroke in the general population. We hypothesised that the presence of concomitant PFO and atrial fibrillation (AF) will add incremental risk of ischaemic stroke to that linked to AF alone. Methods We analysed data on 3069 consecutive patients (mean age 69.4±12.2 years; 67.1% men) undergoing transoesophageal echocardiography-guided electrical cardioversion (ECV) for AF between May 2000 and March 2012. PFO was identified by colour Doppler and agitated saline contrast study. All patients were followed up after ECV for first documentation of ischaemic stroke. Outcomes were compared using Cox regression models. Results The prevalence of PFO was 20.0% and the shunt direction was left-to-right in the majority of patients (71.4%). Patients with PFO had a higher frequency of obstructive sleep apnoea (21.7% vs 17.1%, p=0.01) and higher mean peak left atrial appendage emptying velocity (38.3±21.8 vs 36.1±20.4 cm/s; p=0.04) compared with those without PFO. Otherwise, baseline characteristics were similar between groups. During a mean follow-up period of 7.3±4.6 years, 214 patients (7.0%) had ischaemic stroke. Multivariable analysis showed no significant association between PFO and ischaemic stroke (HR, 0.82 (95% CI 0.57 to 1.18)). PFO shunt direction was strongly associated with stroke: HR, 1.91 (95% CI 1.16 to 3.16) for right-to-left shunt and HR, 0.58 (95% CI 0.36 to 0.93) for left-to-right shunt. Conclusions The presence of concurrent PFO in this largely anticoagulated group of patients with AF was not associated with increased risk of ischaemic stroke.

Introduction: Lack of health equity ultimately leads to unequal treatment of diverse patients and contributes to the growing disparities seen in national health. Academic medical centers should consider providing health care providers and biomedical researchers training on how to identify and address health disparities. Methods: The authors led an introductory health disparities course for graduate students and research and clinical fellows at an academic medical center in the Midwest. We compared pre/postcourse assessments to determine changes in learners’ perceptions and knowledge of health disparities using an unpaired analysis to permit inclusion of responses provided only at baseline. Results: Sixty-two learners completed preassessment, with 56 completing the postassessment (90%). In the postcourse assessment, learners reported an increase in knowledge of disparities and had changes in their perceptions of health disparities linked to treatment of different patient groups based on demographic characteristics. There was a statistically significant difference in learners’ perceptions of how patients are treated based on gender identity (P=0.02) and sexual orientation (P=0.04). Conclusions: The results detail how an academic medical center can provide training on health disparities for diverse learners. This study underscores the influence of health disparities from the perspective of learners who conduct biomedical research and patient care. This course serves a model for introductory-level health disparities courses.