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This study examined the association of aldosterone and plasma renin activity (PRA) with incident cardiovascular disease (CVD), using a composite endpoint of coronary heart disease, stroke, and/or heart failure and mortality among African Americans in the Jackson Heart Study.

To analyze associations between adiposity and the renin-angiotensin-aldosterone system (RAAS) in a large African American (AA) cohort.

Higher levels of ideal cardiovascular health (ICH) are associated with lower levels of aldosterone and incidence of cardiovascular disease (CVD). However, the degree to which aldosterone mediates the association between ICH and CVD incidence has not been explored. Thus, we investigated the mediational role of aldosterone in the association of 5 components of ICH (cholesterol, body mass index (BMI), physical activity, diet and smoking) with incident CVD and the mediational role of blood pressure (BP) and glucose in the association of aldosterone with incident CVD in a cohort of African Americans (AA).

Greater attainment of ideal cardiovascular health (ICH) and lower serum aldosterone are associated with lower diabetes risk. Higher levels of ICH are associated with lower aldosterone. The mediational role of aldosterone in the association of ICH with incident diabetes remains unexplored. Thus, we examined the mediational role of aldosterone in the association of 5 ICH components (smoking, diet, physical activity, body mass index [BMI], and cholesterol) with incident diabetes. Additionally, we investigated the mediational role of glucose and blood pressure (BP) in the association of aldosterone with incident diabetes in an African American (AA) cohort.

Context:Previous research has suggested that activation of the renin-angiotensin-aldosterone system may promote insulin resistance and β-cell dysfunction, but the association with incident diabetes in African Americans is unknown.Objective:We examined the association of aldosterone and renin with insulin resistance, β-cell function, and incident diabetes in a large African American cohort.Design:The Jackson Heart Study is a prospective study of the development and progression of cardiovascular disease in African Americans.Setting:Participants were recruited from the tricounty area of metropolitan Jackson, Mississippi.Participants:A total of 5301 African American adults, aged 21–94 years, were assessed at baseline and through 12 years of follow-up. Data on aldosterone, renin, and risk factors were collected at baseline (2000–2004). Diabetes (fasting glucose ≥ 126 mg/dL, physician diagnosis, use of diabetes drugs, or glycated hemoglobin ≥ 6.5%) was assessed at baseline and through 12 years of follow-up. Participants were excluded for missing data on baseline covariates or diabetes follow-up. Cox regression was used to estimate hazard ratios (HR) for incident diabetes using sequential modeling adjusting for age, sex, education, occupation, systolic blood pressure, current smoking, physical activity, dietary intake, and body mass index.Exposures:Aldosterone, renin, and diabetes risk factors were measured.Outcomes:Outcomes included the homeostatic model assessment of insulin resistance (HOMA-IR) and incident diabetes.Results:Among 3234 participants over a median of 8.0 years of follow-up, there were 554 cases of incident diabetes. Every 1% increase in log-transformed aldosterone was associated with a 0.18% higher log-transformed HOMA-IR in cross-sectional analyses of nondiabetic participants (P< .001). Log-transformed aldosterone and renin levels in the fifth vs first quintile were associated with a 78% (HR 1.78, 95% confidence interval 1.35–2.34) and 35% (HR 1.35, 95% confidence interval 1.06–1.72) increase in diabetes risk, respectively, in fully adjusted models.Conclusions:Activation of the renin-angiotensin-aldosterone system may play a significant role in the development of insulin resistance and diabetes in African Americans.

Patients with AIDS are predisposed to pulmonary embolism (PE). The clinical situation can be confusing when a patient has both PE and an opportunistic pulmonary infection such as Pneumocystis jiroveciipneumonia (PJP), due to their similarities in presentation. This case emphasizes the need for clinicians to have a high index of suspicion and consider PE in the differential diagnoses of dyspnea and hypoxemia, particularly when PJP infection or other AIDS-defining illnesses are suspected.Severe immunosuppression and the presence of opportunistic infections in human immunodeficiency virus/acquired immunodeficiency syndrome are strongly associated with incidence of venous thromboembolism especially deep venous thrombosis and pulmonary embolism (PE). The co-occurrence of 2 diseases with similar clinical presentation can pose diagnostic and treatment challenges. We describe the case of a 54-year-old male, with no significant past medical history who presented with complaints of a 6-week history of shortness of breath. He was diagnosed with human immunodeficiency virus 1 infection with a CD4 count of 121 cells/μL and severe Pneumocystis jiroveciipneumonia. After 5 days of treatment without significant improvement, we obtained a computed tomography pulmonary angiogram, which showed concurrent acute PE. His clinical condition improved with anticoagulation therapy. Clinicians need to have a high index of suspicion and consider PE in the differential diagnosis of dyspnea and hypoxemia, particularly when P. jiroveciipneumonia infection or other acquired immunodeficiency syndrome defining illnesses are suspected.

Background:Safety net hospitals treat a large burden of uninsured, or Medicaid insured patients, and have been linked to worse outcomes across several medical and surgical conditions. Currently, there is limited data on the effect of safety net burden on outcomes of inpatient cardiopulmonary resuscitation (CPR) for patients that suffered in-hospital cardiac arrest (IHCA) in the US.Hypothesis:Patients that experience IHCA in high burden safety net hospitals (HBH) will have worse outcomes compared to low burden safety net hospitals (LBH).Methods:Using the National Inpatient Sample database, from 2008 – 2018, we identified patients aged ≥ 18 years who experienced IHCA, using International Classification of Diseases (ICD) codes. Hospitals’ safety net burden was calculated from the proportions of Medicaid and uninsured patients using previously published methodology and categorized into LBH and HBH. Multivariate regression models were used to estimate the odds of key clinical outcomesResult:From 2008 to 2018, an estimated 555,016 unweighted adult hospitalizations underwent CPR for IHCA, out of which 19.2 % occurred at LBH and 55.2 % occurred at HBH. Compared with LBH, patients at HBH on average were younger 62 years ± 20 vs 67 years ± 17), less likely to be of White race, and more likely to be in the lowest median household income. On multivariate regression analysis, HBH was associated with lower chances of survival to hospital discharge (aOR 0.88; 95% CI 0.85 – 0.96) and lower odds of routine discharge (aOR 0.6; 95% CI 0.47 – 0.75)), compared to LBH. Patients who suffered IHCA in safety net hospitals with medium and large hospital bed size (aOR 0.96; 95% CI 0.94 – 0.98) and those publicly owned (aOR 0.95; 95% CI 0.92 – 0.98) were less likely to survive to hospital discharge. Median household income of patients in the 26th– 100thquartile and hospital location in the Midwest and Southern region were associated with better odds of hospital survival.Conclusion:Our study suggests that patients who experience IHCA at HBH had lower rates and odds of in-hospital survival and also less likely to be routinely discharged home. Patients’ income level and hospital-level characteristics appear to contribute to survival.

Introduction:There is limited data on the gender differences in the trend of hospitalizations related to PAH and associated outcomes in the USMethods:We queried the National Inpatient Sample from 2010 to 2019 to identify PAH admissions using international classification of diseases (ICD) codes 416.0 (ICD-9) and I27.0 (ICD-10)Results:20,513 hospitalizations with PAH as the primary diagnosis was analyzed during the study period. There were 13,928 women (67.9%) and 6,584 (32.1%) men. The mean age among women (SD) and men (SD) were 66 years (16) and 65 years (17) respectively. Between 2010 and 2019, PAH hospitalization rates declined in both women (13.5% vs. 8.5%], P < 0.001) and men (14.2% vs. 8.3%, P = 0.027. The overall mortality rate was higher in men compared with women (6.6% vs. 5.7%, P = 0.015. Though crude mortality rates declined for the total population, this was statistically significant only among women (6.7% vs.5.6%, P = 0.011). On adjusted multivariate analysis, factors associated with increased odds of inpatient mortality among women were age 45 - 64 years (OR 1.62, 95% CI 1.11 - 2.37, P = 0.013) and > 65 years (OR 2.36, 95% CI 1.57 - 3.55, P<0.001) compared with age 18-44 years. Black (OR 1.44, 95% CI 1. 13 - 1.78, P < 0.001) and Hispanic race/ethnicity (OR 1.06, 95% CI 1.02 - 1.51, P = 0.037), compared with White race/ethnicity. Comorbidities and in-hospital complications associated with increased mortality were chronic kidney disease, acute pulmonary embolism (PE), and acute respiratory failure (ARF). Among men, age > 65 years (OR 3.28, 95% CI 1.68 - 6.41, P = 0.001), Black (OR 1.9, 95% CI 1.36 - 2.91, p < 0.001) and Hispanic race/ethnicity (OR 1.21, 95% CI 1.08 - 1.78, P = 0.021), compared with White race/ethnicity were associated with increased odds of mortality. The presence of congestive heart failure and complications of acute PE, ARF, acute ischemic stroke, and atrial fibrillation were also associated with increased mortality.Conclusions:From 2010 to 2019 in the US, PAH-related hospitalization rates decreased in both women and men while mortality only decreased among women. Men were more likely to die during hospitalization compared with women. Older age and Black and Hispanic race/ethnicity were associated with higher mortality in both women and men.

Introduction:Liver cirrhosis affects an estimated 1 in 400 adults in the US with significant morbidity and mortality. There is limited data on the incidence and outcomes of in-hospital cardiac arrest (IHCA) in liver cirrhosis-related hospitalizations.Methods:Using the appropriate international classification of disease codes, we queried the nationwide inpatient database to identify patients hospitalized with a primary diagnosis of liver cirrhosis who experienced IHCA and underwent cardiopulmonary resuscitation, between 2010 and 2019, We evaluated the temporal trends in the in-hospital outcomes using Cochrane -Armitage test, and factors associated with survival to hospital discharge using logistic regression analysis.Results:7,091,054 weighted liver cirrhosis hospitalizations were identified during the study period. The IHCA incidence rate was 1.4% with a mean age (SD) of 59 years (12) and males were predominantly affected (59.9%). There was an upward trend in IHCA incidence during the study period (1.3% in 2010 to 1.5% in 2019, p < 0.001). The overall survival to hospital discharge rate was 22.2%. No significant change in the mortality trend during the study period. Most of the survivors were discharged to a long-term acute care facility (46.4%) followed by home discharge without the need for home health (24.7%) and short-term acute facilities (12.6%). Factors associated with lower odds of survival to hospital discharge were age > 65 years OR 0.71, 95% CI 0.67 - 0.75, P < 0.001), Black (OR 0.94, 95% CI 0.91 - 0.99, P=0.012) and Hispanic race (OR 0.78, 95% CI 0.74 - 0.81, P < 0.001), and severe comorbidity index (OR 0.63, 95% CI 0.59 - 0.65, P < 0.001).Conclusion:Between 2010 and 2019, we found a slight increase in the IHCA incidence rate among patients hospitalized with liver cirrhosis. Only about one out of 5 patients survived hospital discharge, and this did not change during the study period. Low socioeconomic status and higher comorbidity burden were associated with lower odds of survival. More research is needed to identify strategies that may improve survival outcomes in IHCA among liver cirrhosis patients.

Background:Cardiac arrest is a known complication of Pulmonary arterial hypertension (PAH) often due to acute right heart failure and arrhythmias. However, data on trends in the incidence and in-hospital outcomes of in-hospital cardiac arrest (IHCA) among PAH-related hospitalizations in the US is limited.Hypothesis:IHCA incidence has declined and In-hospital outcomes improved among PAH-related hospitalizations.Methods:We identified hospitalizations with a primary diagnosis of PAH in the nationwide inpatient database between 2010 and 2019, using the appropriate international classification of disease codes. We extracted patients who underwent cardiopulmonary resuscitation for IHCA and evaluated temporal trends in the incidence and in-hospital outcomes using the Cochrane-Armitage test. Logistic regression was used to evaluate factors associated with odds of survival to hospital discharge.Results:We identified 18,772 PAH-related hospitalizations during the study period. The IHCA incidence rate was 1.8% with a mean age (SD) of 62 years (16) and females predominantly affected (62.8%). There was a non-significant decline in IHCA incidence rate between 2010 and 2019 (1.9% vs. 1.2%, P=0.08). The overall survival to hospital discharge rate was 30.4% and this increased significantly during the study period (26.7% vs 36.9%, P = 0.04). Most of the survivors were discharged to a long-term acute care facility (44.2%) and 18.% were discharged home without the need for home health care. Factors associated with lower odds of survival were age > 65 years OR 0.97, 95% CI 0.96 - 0.98, P < 0.001), acute right heart failure (OR 0.74, 95% CI 0.60 - 0.90, P<0.001), acute respiratory failure (OR 0.20, 95% CI 0.16 - 0.24, P < 0.001), and severe comorbidity index (OR 0.83, 95% CI 0.71-0.96, P < 0.001). The presence of shockable rhythm (OR 1.67, 95% CI 1.31 - 2.26, P=0.03) and obesity (OR 1.33, 95% CI 1.02 - 1.72, P=0.03) were associated with higher odds of survivalConclusion:Though IHCA survival among resuscitated PAH-related hospitalizations improved during the 10-year study period in the US, only about 3 out of 10 patients still survive to hospital discharge. Additional studies are warranted to identify strategies that will improve resuscitation outcomes in these patients.

Introduction:There is limited data on racial disparities in the outcomes of PPCM complicated by cardiogenic shockMethods:We identified 5,838 patients hospitalized with the PPCM and CS from the 2007 to 2018 National Inpatient Sample, of which 2214 (38%) were White, 3006 (51.4%) Black, and 618 (11%) Hispanic. Cochrane Armitage test and multivariable logistic regression were used to assess the temporal trends in the incidence of CS among patients with PPCM stratified by the racial group stated above. In addition, we compared in-hospital mortality, systemic thromboembolism, mechanical circulatory support (MCS) use (intra-aortic balloon pump, temporal ventricular assist device, extracorporeal membrane oxygenation), heart transplant referral in Blacks and Hispanics compared to Whites using multivariable logistic regression.Results:The mean age of the study sample was 34 +/- 8. An increase was noted in the incidence of CS in PPCM among all racial groups from 2007 to 2018 (Whites; 0.8% to 4.1%, Blacks; 0.3% to 8.5%, Hispanics; 2.4% to 2.9%, P < 0.0001 for all). After adjusting for confound variables at baseline, the adjusted odds ratio for in-hospitality remained significantly higher in Hispanics and Blacks than whites. MCS and heart transplant referral were lower in Blacks than Whites (Table 1). Most significant factors associated in-hospital mortality among patients with PPCM and CS included baseline chronic kidney disease, chronic hemodialysis, and mechanical circulatory support useConclusions:We found an incidence rate of 2.1% for CS in PPCM. Though there was an upward trend in the incidence across all ethnicities during the study period, the increase was most striking among African Americans. Hispanics and African Americans were more likely to die and less likely to be referred for heart transplant compared to Whites. African Americans were more likely to be treated with MCS compared to Whites.

Background:Multiple observational studies have demonstrated an increased risk for cardiovascular (CV) events in patients with inflammatory bowel disease (IBD). However, it is unclear if the risk of CV outcomes is greater among patients with coexisting IBD and coronary artery disease (CAD), compared to those with CAD alone.Method:We recruited 755,361 adults aged 18 - 75 years with CAD and IBD (5173 had coexisting CAD and IBD) from the 2012 database of the National Inpatient Sample. IBD included ulcerative colitis (UC) and Crohn?s disease (CD). Our CV outcomes of interest were: acute coronary syndrome, sudden cardiac death, stroke, mesenteric ischemia, and overall mortality. All clinical characteristics were defined as per the International Classification of Diseases 9th revision codes. Logistic regression analysis was used to estimate the adjusted odds ratios (aOR) of outcomes among participants with CAD alone and coexisting CAD/IBD, while accounting for co-morbidities and this was compared to those with CAD alone.Results:The mean age was 62?9 (38% women, 69% White, 26% Blacks). Rates of sudden cardiac death were comparable among those with coexisting UC/CAD, compared to those with CAD alone (1.1% vs 1.1%), and lowest in those with coexisting CD/CAD (0.5%). Mesenteric ischemia was highest among those with UC/CAD compared to those with CD/CAD or CAD alone (1.1% vs 0.7% vs 0.3%, respectively, P < 0.001). Overall mortality was highest among participants with coexisting UC and CAD (2.9%), compared to those with CD and CAD (1.4%) or CAD alone (2.1%) P <0.05. Table 1 displays the aOR of CV outcomes by disease condition compared to participants with CAD alone, the aOR for sudden cardiac death and overall mortality were significantly higher among those with UC/CAD, whereas the aOR was lower for those with CD/CAD.Conclusion:The coexistence of UC and CAD is associated with a higher risk of sudden cardiac death and overall mortality, compared to CAD alone.

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