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There is no clear consensus on a lower cutoff value for normal left ventricular ejection fraction (EF) and the prognostic implications of low normal EF (LNEF) are poorly understood, particularly in Blacks. Therefore, we investigated the association of LNEF and incident heart failure (HF) in a community-based cohort of Blacks. We studied 3,669 participants (mean age 54 years, 63% women) of the Jackson Heart Study without prevalent HF or coronary heart disease (CHD). Participants were divided into three groups: (1) Reduced EF (

According to the Fourth Universal Definition of myocardial infarction (MI), the likelihood of a previous MI is increased when ST-T abnormalities exist with minor Q-waves in the same leads. Therefore, we examined whether differences in location of ST-T abnormalities in relation to minor Q-waves as part of the old MI definition impact the prevalence and prognostic significance of MI. This analysis included 7,878 participants with available baseline electrocardiogram (ECG) and follow-up data from the third National Health and Nutrition Examination Survey. Two ECG MI definitions were utilized; both were based on the standards of the Minnesota Code (MC) ECG Classification, and both incorporated major Q-waves but differed in whether major ST-T abnormalities and minor Q waves, as part of the definition, were in the same lead group (Standard MC-MI) or not (Fourth Universal MI). All-cause mortality and cardiovascular disease mortality were ascertained during 14 years (median). We found no difference between baseline prevalence of Standard MC-MI (3.48%; n = 274) and Fourth Universal MI (3.27%; n = 258), p = 0.46. Also, Standard MC-MI and Fourth Universal MI were similarly associated with increased risk of all-cause mortality (hazard ratio [95% confidence interval] 1.64 [1.42 to 1.90] and 1.61 [1.38 to 1.87], respectively; p value for differences in associations = 0.86), and cardiovascular disease mortality (hazard ratio [95% confidence interval] 1.99 [1.61 to 2.48] and 1.94 [1.56 to 2.42], respectively; p value for differences in associations = 0.84). In conclusion, the location of ST-T abnormalities accompanying minor Q-waves does not impact the prevalence or prognostic significance of a prior MI which raise doubts about the clinical impact of considering the location of ST-T in relation to minor Q-waves when defining an old MI.

BACKGROUND: Patients with heart failure (HF) with preserved ejection fraction (HFpEF) and obesity display a number of pathophysiologic features that may render them more or less vulnerable to negative effects of decongestion on renal function, including greater right ventricular remodeling, plasma volume expansion, and pericardial restraint. We aimed to contrast the renal response to decongestion in obese compared to non-obese HFpEF METHODS AND RESULTS: NIH heart failure network studies that enrolled patients with acute decompensated HFpEF (EF≥50%) were included [DOSE, CARRESS, ROSE and ATHENA]. Obese HFpEF was defined as a body mass index (BMI) ≥30 kg/m(2). Compared to non-obese HFpEF (n=118), patients with obese HFpEF (n=214) were an average of 9 years younger (71 vs 80 years,0.5mg/dl) (9 vs 0%, p=0.002). CONCLUSION: Despite being nearly a decade younger, obese HFpEF patients experience greater deterioration in renal function during decongestion compared to non-obese HFpEF. Further study to elucidate the complex relationships between volume distribution, cardiorenal hemodynamics and adiposity in HFpEF are needed.

Given the availability of an effective but expensive lipid-lowering medication, proprotein convertase subtilisin/kexin type 9 inhibitors, the American Heart Association and the American College of Cardiology 2018 cholesterol guideline introduced a new classification of “very high-risk” (i.e.

Coronary artery calcium (CAC) scoring has emerged as a useful tool in identifying patients who may benefit from more aggressive risk factor modification and for prognostication. Although a CAC score of 0 is associated with a very low prevalence of obstructive epicardial coronary artery disease and low event rates, it can also provide a false sense of reassurance. We present a case of a 39-year-old woman with a CAC score of 0 obtained as part of a coronary computerized tomography angiography study that was ultimately found to have significant left anterior descending artery disease requiring percutaneous coronary intervention and a stent.

Introduction: Elevation in the inflammatory marker high sensitivity C-reactive protein (hsCRP) is associated with worse outcomes in patients with heart failure (HF). We aimed to determine if baseline or trajectory of hsCRP levels over time predict incident HF hospitalization. Methods: Jackson Heart Study (JHS) participants’ (n=4203 African Americans) hsCRP levels were measured over 3 visits (visit 1: 2000 to 2004; visit 2: 2005 to 2008; visit 3: 2009 to 2013). We assessed the association of a single hsCRP level measurement at baseline (visit 1) with incident HF hospitalization using Cox proportional hazard models. Furthermore, we assessed the association of trajectory of hsCRP over repeated measurements (visit 1-3) with incident HF using a joint model, which incorporates estimated hsCRP from a linear mixed effects model into a Cox hazards model to predict incident HF hospitalization while incorporating trajectory of hsCRP over visits. All hazard ratios (HR) are presented as an increase in hsCRP by 1 standard deviation on a Log 2 scale. Results: At baseline, mean age of participants was 55±13 years, 63.4% were women, and mean hsCRP level was 0.5±0.7 mg/dl. Over a median follow-up of 12 years, 353 (8.4%) participants were hospitalized with incident HF. After adjustment for covariates, baseline hsCRP was not associated with increased risk of incident HF hospitalization (Table, p>0.05). However, increases in hsCRP levels on follow-up were associated with a significantly increased risk of incident HF hospitalization (Table, p Conclusions: While an elevated hsCRP level at one time point may not be associated with incident HF, the increasing trajectory of change in hsCRP over time is predictive of increased risk for incident HF hospitalization in African Americans. These data support the role of increased inflammatory status in the development of heart failure.

Background: The AHA/ACC 2018 Cholesterol Guideline categorizes ASCVD patients into very high-risk vs. high-risk to guide intensive therapy. This categorization is based on clinical conditions, including reduced kidney function, but does not take into account albuminuria, the other kidney measure often available in clinical practice. Methods: We studied 838 participants with major ASCVD (myocardial infarction, ischemic stroke, or symptomatic peripheral artery disease) from the ARIC study at baseline (1996 - 98). We compared urine albumin-to-creatinine ratio (ACR) and the eight high-risk conditions of age 65+, reduced kidney function, diabetes, etc. in the AHA/ACC Guideline regarding their associations with composite outcome of all-cause mortality, myocardial infarction, ischemic stroke, and heart failure. We also evaluated risk classification by adding ACR to the eight high-risk conditions. Results: During a median follow-up of 8 years, 724 (86%) participants developed a composite outcome. ACR ≥30 mg/g was associated with the composite outcome (adjusted hazard ratio [aHR] 1.45 [95% CI 1.20, 1.75]) beyond the eight high-risk conditions (aHR of these conditions ranged from 0.96 to 2.46). The addition of ACR improved the c-statistic by 0.011 (95% CI 0.003-0.019) from 0.661 to 0.672. ACR classified 4.6% of high-risk group to very high-risk and 11.2% of very high-risk group to extremely very high-risk with a reasonable calibration (Figure). Even ACR ≥10 mg/g showed a significant aHR of 1.38 (1.17, 1.63) and classified 13.4% of high-risk and 18.1% very high-risk to a higher risk category. Of our patients with ASCVD, 77% had diabetes, hypertension, or low kidney function, clinical conditions in which the ACR assessment is recommended. Conclusions: In ASCVD, albuminuria was a strong predictor of major adverse cardiovascular outcome and improved risk prediction. Clinicians should pay attention to albuminuria, in addition to eGFR, when managing ASCVD patients.

Background Recent evidence suggests a link between myocardial infarction and stroke risk, but it is unclear whether such risk exists with electrocardiographic myocardial injury in otherwise healthy individuals. Therefore, we explored the association of myocardial injury with stroke mortality in participants free of cardiovascular disease. Methods This analysis included 6017 participants (58.4 ± 13.4 years, 54.1% women, 50.3% white) from the Third National Health and Nutrition Examination Survey. Cardiac infarction/injury score (CIIS), a weighted scoring system composed of several electrocardiographic waveform components related to myocardial injury and ischemia, was used to define myocardial injury. Stroke mortality was ascertained using the National Death Index during follow-up. Multivariable adjusted Cox proportional hazard analysis was used to examine the association between baseline myocardial injury and risk of stroke mortality. Results Over a median follow-up of 14 years, 152 stroke deaths occurred. Stroke mortality was more common in those with than those without myocardial injury (3.8% vs. 2.1%, respectively; p = 0.0003). In a model adjusted for potential confounders, the myocardial injury was associated with a 44% increased risk of stroke mortality (HR (95%CI):1.44(1.02–2.03)). In a similar model, each 1 CIIS score point increase was associated with a 2% increase in the risk of stroke mortality (HR (95%CI):1.02 (1.00–1.04), p = 0.01). Conclusions Electrocardiographic myocardial injury in cardiovascular disease-free adults is associated with an increased risk of stroke mortality suggesting a potential link between asymptomatic myocardial injury and risk of cardiac thromboembolism. Whether screening and management of myocardial injury would reduce such risk requires further investigation.

Background Accurate calculation of stroke volume (SV) by Doppler echocardiography is important for the assessment of aortic stenosis (AS), which may be impacted by anatomical variations of left ventricular outflow tract (LVOT). Methods Patients with AS (n = 64) were studied using computed tomography (CT) and transthoracic echocardiography (TTE). Anatomical variations of LVOT areas were measured at (a) the aortic annulus (Aa ); (b) 5 mm (A5 ); and (c) 10 mm below the annulus (A10 ) by CT. LVOT diameters were also measured by 2D TTE at these three levels for calculation of LVOT areas. Stroke volumes (SV) were calculated using continuity equation. The impacts of anatomical variations of LVOT on SV calculation were evaluated. Results Anatomical LVOT area increased from Aa to A10 (5.0 ± 0.9 cm2 vs 5.8 ± 1.9 cm2 , P .05), the most significant variations in individuals were at A10 levels (ΔSV: 8.2 ± 6.4 mL, 12 ± 9%). Conclusion Variations of LVOT anatomy in individuals with AS significantly impact the SV calculated by Doppler echocardiography. These features should be taken into account for AS diagnosis and a clinical decision-making for intervention.

Objectives To investigate glucose levels as a risk factor for unrecognized myocardial infarctions (UMIs). Design Cohort Setting Cardiovascular Health Study. Participants Individuals aged 65 and older with fasting glucose measurements (N=4,355; normal fasting glucose (NFG), n = 2,041; impaired fasting glucose (IFG), n = 1,706; DM: n = 608; 40% male, 84% white, mean age 72.4 ± 5.6). Measurements The relationship between glucose levels and UMI was examined. Participants with prior coronary heart disease (CHD) or UMI on initial electrocardiography were excluded. Using Minnesota codes, UMI was identified according to the presence of pathological Q‐waves or minor Q‐waves with ST‐T abnormalities. Crude and adjusted hazard ratios (HRs) were calculated. Analyses were adjusted for age, sex, body mass index (BMI), hypertension, antihypertensive and lipid‐lowering medication use, total cholesterol, high‐density lipoprotein cholesterol, and smoking status. Results Over a mean follow‐up of 6 years, there were 459 incident UMIs (NFG, n=202; IFG, n=183; DM, n=74). Participants with IFG were slightly more likely than those with NFG to experience a UMI (hazard ratio (HR)=1.11, 95% confidence interval (CI)=0.91–1.36, p = .30), and those with DM were more likely than those with NFG to experience a UMI (HR=1.65, 95% CI=1.25–2.13, p

ObjectiveThe cross-sectional association between accelerometer-measured physical activity (PA), sedentary behaviour (SB) and cardiac structure and function is less well described. This study’s primary aim was to compare echocardiographic measures of cardiac structure and function with accelerometer measured PA and SB.MethodsParticipants included 1206 self-identified Hispanic/Latino men and women, age 45–74 years, from the Echocardiographic Study of Latinos. Standard echocardiographic measures included M-mode, two-dimensional, spectral, tissue Doppler and myocardial strain. Participants wore an Actical accelerometer at the hip for 1 week.ResultsThe mean±SE age for the cohort was 56±0.4 years, 57% were women. Average moderate to vigorous PA (MVPA) was 21±1.1 min/day, light PA was 217±4.2 min/day and SB was 737±8.1 min/day. Both higher levels of light PA and MVPA (min/day) were associated with lower left ventricular (LV) mass index (LVMI)/end-diastolic volume and a lower E/e′ ratio. Higher levels of MVPA (min/day) were associated with better right ventricular systolic function. Higher levels of SB were associated with increased LVMI. In a multivariable linear regression model adjusted for demographics and cardiovascular disease modifiable factors, every 10 additional min/day of light PA was associated with a 0.03 mL/m2 increase in left atrial volume index (LAVI) (p2 increase in LAVI (pConclusionsOur findings highlight the potential positive association between the MVPA and light PA on cardiac structure and function.

Background While echocardiography is effective for initial identification of anatomic location, magnetic resonance imaging (MRI) is a more advantageous modality for delineating tumor expanse, spread, and blood supply preoperatively. Emerging patterns may even help generate a specific diagnosis prior to biopsy and histopathology. Case Presentation Our case of a 67-year-old male referred for cardiac magnetic resonance to further evaluate a cardiac mass highlights the sophisticated level of data which can be collected. Our case highlights the perfusion related findings associated with cardiac angiosarcoma. Conclusion In this case, we present the diagnosis of right atrial cardiac angiosarcoma by multiple imaging modalities including MRI and subsequent angiography, allowing for prompt surgical intervention and initiation of adjuvant therapy that resulted in a survival time of 19 months.

Background: With the proliferation of echocardiography, clinicians are detecting more patients with valve disease and identifying valve disease much earlier in its natural course. Understanding the gender and racial differences in prevalence of valve disease may help guide clinicians to allocate resources in researching strategies to prevent progression of valve disease. Methods: We identified 9,625 patients from the echocardiography laboratory database between September 2013 to April 2018 who had a LV ejection fraction ≥ 50%. Data related to left-sided valvular disease, baseline demographics, and clinical history were obtained from our clinical data repository. Crude analyses by sex and race were performed to identify the prevalence of certain valve lesions. Logistic regression was used to adjust these relationships by baseline demographics. Results: Our population was 58% female, 21% African-American (AA) with a mean age of 59 ± 17 years. For moderate/severe aortic stenosis (AS), AA had 2.4% compared to 7.5% in Caucasians (CA; p0.2), and women had 4.0% compared to 5.4% for men (p=0.003). For moderate/severe mitral regurgitation, AA had 6.6% vs 7.8% for CA (p=0.056), and women had 8.3% vs 6.3% for men (p=0.003). Adjusting for age, race, sex, height, and weight, AA had lower odds ratio (OR) for AS than CA (OR: 0.47; 95% CI: 0.34-0.64; p Conclusion: African-Americans have a lower prevalence of moderate/severe aortic stenosis than Caucasians. Compared to men, women have a lower prevalence of moderate/severe aortic stenosis, lower prevalence of moderate/severe aortic regurgitation, but a higher prevalence of mitral regurgitation.

Previous trials definitively established that lowering systolic blood pressure (BP) to 140 mmHg prevented heart failure (HF) exacerbations, but the potential benefits and risks of further BP reduction remain unclear due to a paucity of trial-based data. A recent secondary analysis of the Systolic Blood Pressure Intervention Trial (SPRINT) found that in older, high-risk, non-diabetic participants with systolic hypertension, a BP treatment target

Approximately 45% of first of myocardial infarctions (MI) are silent. People with diabetes are more likely to have MIs than those without diabetes. Little is known, however, about silent MIs (SMIs) among those with prediabetes. The prognosis of SMIs is similar to clinical MIs making timely detection imperative. We aimed to assess the association between prediabetes and incident SMI in four long duration cohort studies. We pooled data from the following studies: Cardiovascular Health, Atherosclerotic Risk in Communities, Health Aging and Body Composition, and Multi-Ethnic Study of Atherosclerosis (n=30,898). Population characteristics were: mean age 61.3 years, 45% male, 66.4% white, 40.0% had hypertension and 35.3% had hyperlipidemia. Diabetes status was based on fasting glucose (100-125mg/dL=prediabetes and >=126mg/dL=diabetes). Participants were also defined as having diabetes if they were taking medications for diabetes or reported a previous diagnosis. At baseline, 36% did not have diabetes, 50% had prediabetes and 14% had diabetes. Among participants with prediabetes, 3% experienced SMI over a mean follow-up of 9.6 years compared with 2% among those without diabetes. In Cox Proportional Hazards Models, we found an increased risk of incident SMI among those with prediabetes compared to those without diabetes (Hazard Ratio=1.25; 95% CI: 1.04-1.5, p=0.02), adjusting for age, sex, race, smoking status, hypertension, and high cholesterol. Significant baseline predictors of SMI in addition to having prediabetes included being male, older age, current smoking, and hypertension. People with prediabetes, comprising 50% of these cohort study populations, may be at increased risk for SMI, and could benefit from increased focus on prevention and treatment of cardiovascular risk factors. Disclosure J.C. Zgibor: None. M. Malmi: None. W. Wang: None. K.E. Kip: None. D.D. Schocken: None. A.C. Alman: None. R.B. Stacey: None.

Prediabetes affects almost 40% of the United States, a significant proportion of the population. While most readily recognize the risks imposed by diabetes mellitus, fewer clinicians and patients recognize the potential risks associated with being diagnosed with prediabetes. Diabetes causes both micro- and macrovascular complications. The prevention of these complications serves as a significant target of evidence-based guidelines. Data continue to emerge that many of these classic complications associated with diabetes mellitus actually initiate and potentially manifest during the prediabetic state. Even marginally elevated blood glucose levels increase systemic inflammation and with atherosclerosis being a type of arterial injury and its inflammatory response, it should come as no surprise that prediabetics have a greater atherosclerotic burden than their normal glycemic counterparts. Furthermore, many patients who initially present with a myocardial infarction are found to be prediabetic, and prediabetics experience more cardiovascular events after having a myocardial infarction. In diabetics, silent myocardial infarctions represent the intersection of the recognizing macro- and microvascular complications. Emerging data indicate that prediabetics also develop silent myocardial infarctions. The most efficacious means available to prevent the risks imposed by prediabetes and prevent the progression to overt diabetes mellitus remains exercise and dietary changes. With a substantial segment of the population being prediabetic, public health measures should continue to reinforce the critical nature of a heart healthy lifestyle featuring exercise and prudent dietary choices to prevent the cardiovascular morbidity and mortality associated with an abnormal blood glucose level.

This is a case of a 48-year-old man who presented with a pulmonary embolism and was found to have left ventricular non-compaction cardiomyopathy. Initial echocardiograms demonstrated prominent apical trabeculations with reduced biventricular function. These findings were further confirmed and characterized by cardiac magnetic resonance imaging. He met all major criteria used to identify left ventricular non-compaction cardiomyopathy. He underwent medical management for heart failure and during follow-up was noted to have significant improvement in left ventricular systolic function and symptoms. While most management attention is focused on rhythm disturbances or embolic risk, particular attention should also be exercised to ensure that heart failure medical therapy is optimized. While many with left ventricular non-compaction cardiomyopathy have irreversible dysfunction, this case highlights that there may be some who will respond well to aggressive medical therapy. The diagnosis and medical management of left ventricular non-compaction cardiomyopathy are reviewed in light of our patient and his clinical course.

Background Unexplained sudden death is common among patients with sickle cell diseases (SCD). QTc prolongation is a risk factor for fatal arrhythmias among adults. This study sought to identify the predictors for QTc prolongation and determine whether QTc prolongation is associated with increased mortality in patients with SCD. Methods We reviewed the electrocardiograms (EKG) and the transthoracic echocardiograms (TTE) of 140 consecutive adults (>18 years) with SCD from October 1996 to January of 2012. QTc prolongation was categorized into three gender-specific categories based on previous publications. Stepwise regression was performed to evaluate QTc interval and mortality as dependent variables. Hemolytic burden as reflected in laboratory evaluation, diastolic, and systolic TTE variables were included in this model. Results In a stepwise regression analysis, only increased tricuspid regurgitant jet velocity (TRV) (r = 0.483, P = 0.015) had a significant association with QTc interval. Among 49 (35%) patients, the QTc interval was persistently prolonged (PP) (>450 ms in men, >470 ms in women). Twenty-one patients (15%) died over 9 years of follow-up. PP QTc was associated with increased mortality (HR; 8.3 with 95% CI: 2.8–24.6, P

Background: Almost 25% of initial myocardial infarctions (MI) are unrecognized or clinically-silent (UMI). The prognostic implications of a UMI parallel those of symptomatic MIs. With diabetes mellitus (DM) being a known risk factor for UMI, further investigation is warranted regarding impaired fasting glucose (IFG) as a risk factor for UMI. Up to one-third of Americans have IFG . Therefore the relationship between UMI and IFG may have significant public health and clinical ramifications. Methods: The relationship between IFG and UMI was examined in the Cardiovascular Health Study: a cohort of individuals aged ≥ 65 years old. At year 2, there were 5,018 participants who had an initial 12-lead electrocardiogram (ECG). Of these participants, those with prior coronary heart disease (CHD), incident CHD, or a UMI on initial ECG were excluded. Our study population consisted of 1,714 participants without exclusions with measured fasting glucose (normal fasting glucose, NFG; n = 844), IFG (n=679), and DM (n=191) who underwent a baseline 12-lead electrocardiogram (ECG). Using Minnesota code, an UMI was identified by the presence of pathological Q waves or minor Q waves with ST-T abnormalities. Crude and adjusted hazard ratios (HRs) were calculated. Cox proportional hazard models were used to adjust for age, gender, body mass index, hypertension, anti-hypertensive medication use, total cholesterol, HDL cholesterol, lipid-lowering medication use, and cigarette use. Results: The sample was 36% male, 95% white, and had a mean age of 72.4 ± 5.6 years. Over a mean follow-up of 8.1 years, there were 94 UMIs identified among NFG subjects, 110 among IFG subjects, and 35 among DM subjects. Relative to NFG, the crude risk ratio estimates for UMI with IFG and DM were 1.53 (95% CI: 1.16-2.01) and 1.85 (1.24-2.70), respectively. With adjustment, the HR for UMI in IFG compared with NFG was 1.37 (95% CI: 1.03-1.83; p=0.032), and the HR for UMI in DM compared with NFG was 1.59 (95% CI: 1.24-2.70; p=0.035). Conclusion: Impaired fasting glucose increased the risk for a subsequent unrecognized myocardial infarction. Considering the enormous number of individuals at risk, these findings suggest the need for more aggressive CVD prevention activities.

Background Dobutamine associated left ventricular (LV) wall motion analyses exhibit reduced sensitivity for detecting inducible ischemia in individuals with increased LV wall thickness. This study was performed to better understand the mechanism of this reduced sensitivity in the elderly who often manifest increased LV wall thickness and risk factors for coronary artery disease. Methods During dobutamine cardiovascular magnetic resonance (DCMR) stress testing, we assessed rate pressure product (RPP), aortic pulse wave velocity (PWV), LV myocardial oxygen demand (pressure volume area, PVA, mass, volumes, concentricity, and the presence of wall motion abnormalities (WMA) and first pass gadolinium enhanced perfusion defects (PDs) indicative of ischemia in 278 consecutively recruited individuals aged 69 ± 8 years with pre-existing or known risk factors for coronary artery disease. Each variable was assessed independently by personnel blinded to participant identifiers and analyses of other DCMR or hemodynamic variables. Results Participants were 80% white, 90% hypertensive, 43% diabetic and 55% men. With dobutamine, 60% of the participants who exhibited PDs had no inducible WMA. Among these participants, myocardial oxygen demand was lower than that observed in those who had both wall motion and perfusion abnormalities suggestive of ischemia (p = 0.03). Relative to those with PDs and inducible WMAs, myocardial oxygen demand remained different in these individuals with PDs without an inducible WMA after accounting for LV afterload and contractility (p = 0.02 and 0.03 respectively), but not after accounting for either LV stress related end diastolic volume index (LV preload) or resting concentricity (p = 0.31-0.71). Conclusions During dobutamine stress testing, elderly patients experience increased LV concentricity and declines in LV preload and myocardial oxygen demand, all of which are associated with an absence of inducible LV WMAs indicative of myocardial ischemia. These findings provide insight as to why dobutamine associated wall motion analyses exhibit reduced sensitivity for identifying inducible ischemia in elderly. Trial registration This study was registered with Clinicaltrials.gov (NCT00542503).

Current data supports a link between arterial remodeling and cardiovascular risk. This analysis investigates whether ascending aortic index (AAI) improves the risk assessment by the Framingham 10-year general cardiovascular risk score (FGCRS) for cardiovascular events and mortality. We also analyze

Most measures of LV noncompaction cardiomyopathy (LVNC) are acquired from 2-D assessments. This study describes the changes in trabeculated volume during the cardiac cycle and its relationship to events related to LVNC. We retrospectively identified 122 cases of cardiac magnetic resonance with

Background Abnormal resting arterial stiffness is present in middle‐aged and elderly persons with abnormalities of fasting glucose (diabetes or impaired fasting glucose) and is associated with exercise intolerance. We sought to determine whether these same persons exhibited stress‐related abnormalities of arterial stiffness. Methods and Results We analyzed dobutamine magnetic resonance stress imaging results from 373 consecutively recruited persons aged 55 to 85 years with normal fasting glucose, impaired fasting glucose, or diabetes who were at risk for but without symptomatic heart failure. Personnel blinded to participant identifiers measured arterial stiffness (brachial pulse pressure/left ventricular stroke volume indexed to body surface area, the aortic elastance index [brachial end‐systolic pressure/left ventricular stroke volume indexed to body surface area], and thoracic aortic distensibility) at 80% of the maximum predicted heart rate response for age. Participants averaged 69±8 years of age; 79% were white, 92% were hypertensive, and 66% were women. After accounting for hypertension, sex, coronary artery disease, smoking, medications, hypercholesterolemia, and visceral fat, we observed an effect of glycemic status for stress measures of arterial stiffness in those with diabetes and impaired fasting glucose relative to those with normal fasting glucose ( P =0.002, P =0.02, and P =0.003, respectively). Conclusion Middle‐ and older‐aged individuals with diabetes or impaired fasting glucose have higher stress measures of arterial stiffness than those with normal fasting glucose. These data emphasize the need for future studies with larger sample sizes to determine whether stress‐related elevations in arterial stiffness are related to exercise intolerance and future episodes of heart failure experienced by those with abnormalities of fasting glucose. Clinical Trial Registration URL: http://clinicaltrials.gov/ . Unique identifier: NCT00542503.

OBJECTIVE The assessment of right ventricular (RV) perfusion defects has remained challenging during vasodilator stress perfusion with cardiovascular magnetic resonance (CMR). The significance of RV signal abnormalities during vasodilator stress perfusion and late gadolinium-enhanced CMR is yet uncertain. METHODS Among 61 individuals who underwent adenosine CMR stress testing before cardiac catheterization, we assessed the severity of coronary artery stenoses, mortality, the presence of stress and rest perfusion defects, as well as the presence of late gadolinium enhancement (LGE). RESULTS Right ventricular stress-induced perfusion defects were positively associated with left anterior descending artery and proximal right coronary artery stenoses but were negatively associated with left circumflex artery stenoses. The presence of RVLGE was associated with mortality, but 77% of those with RVLGE also had left ventricular LGE. CONCLUSIONS Proximal right coronary artery and left anterior descending artery stenoses are positively associated, whereas left circumflex artery stenoses are negatively associated with RV stress-induced perfusion defects. Right ventricular LGE was associated with mortality, but further study is needed to determine whether this is independent of left ventricular LGE.

Background: It has been estimated that approximately 25% of initial myocardial infarctions (MI) are unrecognized (UMI). The prognostic implications of UMI’s have been shown to be as severe as those of symptomatic MI’s. Risk factors for UMI’s are not well understood. Because diabetes mellitus is known to be a risk factor for UMI, it is reasonable to investigate impaired fasting glucose (IFG) as a candidate risk factor. Additionally, it has recently been estimated that up to one-third of all adult Americans have IFG. Methods: The relationship between IFG and UMI was examined in the Multi-Ethnic Study of Atherosclerosis (MESA): a cohort of individuals aged 45 to 84 years without clinical cardiovascular disease. At baseline, participants with normal fasting glucose (NFG; n = 4955) and IFG (n=930) underwent a baseline 12-lead electrocardiogram (ECG). Using Minnesota code, an UMI was identified by the presence of pathological Q waves or minor Q waves with ST-T abnormalities. Crude and adjusted odds ratios (ORs) were calculated. Logistic regression was used to adjust for covariates in 2 models. Model 1 adjusted for age, race, gender, and body mass index. Model 2 adjusted for model 1 + systolic blood pressure, diastolic blood pressure, anti-hypertensive medication use, total cholesterol, HDL cholesterol, lipid-lowering medication use, and cigarette use. Results: The sample was 46% male, 41% white, 26% black, 20% Hispanic, and 12% Asian. There were 72 UMIs identified in the normal fasting glucose (NFG) subjects and 30 UMIs among the IFG subjects. The two corresponding prevalences (1.4% vs. 3.2%) resulted in a crude OR for UMI of 2.26 (95% Confidence Interval (CI): 1.47-3.48; p Conclusion: Unrecognized myocardial infarctions by electrocardiogram are associated with impaired fasting glucose in a population without overt cardiovascular disease. Because of the high prevalence of impaired fasting glucose, the implications of this finding may have ramifications for a large proportion of the adult population.

Background: Previously, it was demonstrated that systolic measures identify higher levels of risk for events related to left ventricular noncompaction cardiomyopathy (LVNC) than diastolic measures. This analysis seeks to improve the ability of the diastolic measures to identify LVNC and predict associated events. Methods: Trabeculation/possible LVNC by cMRI was retrospectively observed among 122 consecutive cases. We assessed the extent of trabeculation, end-systolic noncompacted-to-compacted ratios (ESNCCR), end-diastolic noncompacted-to-compacted ratios (EDNCCR) along with myocardial thickening (MT) and ejection fraction (EF). Deaths, CHF readmissions, ventricular arrhythmias, and embolic events were pooled to increase statistical power and used to identify potential LVNC-associated events. Using logistic regression with an ESNCCR ≥ 2 to identify LVNC as the dependent variable and EDNCCR as the independent variable, analysis were performed with receiver operating curves with and without myocardial thickening as a covariate. Next, using pooled LVNC-associated events as the dependent variable, separate models were performed for ESNCCR ≥ 2 and EDNCCR ≥ 2.3, both adjusting for age, race, gender, body surface area, left ventricular ejection fraction, number of trabeculated segments, and myocardial thickening. Results: The area under the curve (AUC) for EDNCCR to identify potential LVNC was 0.84, but with adjustment for myocardial thickening, the AUC was 0.98, which was significantly increased (p-value = 0.005). Without adjusting for myocardial thickening, ESNCCR ≥ 2 was associated with LVNC-associated events, but EDNCCR ≥ 2.3 was not (p-value: 0.003 vs 0.2, respectively). With adjustment for myocardial thickening, both ESNCCR ≥ 2 and EDNCCR ≥ 2.3 were associated with LVNC-associated events (p-value: 0.03 vs 0.03, respectively). Conclusion: In using the diastolic measure to assess for possible left ventricular noncompaction cardiomyopathy, impaired function of the underlying compacted layer is important in identifying those with a higher risk of subsequent events. Further studies are needed to determine if individuals with increased trabeculations with preserved myocardial thickening are at increased risk of future events.

The distinction between normal right ventricular (RV) trabeculations from abnormal has been difficult. We evaluated whether RV volume and function are related to left ventricular (LV) noncompaction (NC) cardiomyopathy and clinical events. Trabeculations or possible LVNC by cardiac magnetic resonance imaging was retrospectively observed among 105 consecutive cases. We measured LV end-systolic (ES) noncompacted-to-compacted ratio, RV ejection fraction (EF), RV apical trabecular thickness, and RV end-diastolic (ED) noncompacted-to-compacted ratio. A control group of 40 subjects was also reviewed to assess the exploratory measures. Comparing those with LVES noncompacted-to-compacted ratio ≥2, those with LVES noncompacted-to-compacted ratio2, and the normal control group, adjusted means for RV apical trabecular thickness and RVED noncompacted-to-compacted ratio were generated. Logistic regression was used to evaluate the association of composite events traditionally associated with LVNC with RVEF after adjustment for aforementioned covariates, cardiovascular risk factors, delayed enhancement, LVEF, and LVES noncompacted-to-compacted ratio. Analysis of RV morphology found greater apical trabecular thickness among those with LVES noncompacted-to-compacted ratio ≥2 compared with those with LVES noncompacted-to-compacted ratio2 or normal control group (31 ± 5 vs 27 ± 2.6 vs 22 ± 4 mm; p = 0.03 and p = 0.003, respectively). There was no difference between the groups in relation to the RVED noncompacted-to-compacted ratio. Low RVEF and LVES noncompacted-to-compacted ratio ≥2 had significant association with clinical events in this population even after adjusting for clinical and imaging parameters (p = 0.04 and p0.001, respectively). In conclusion, RV dysfunction in a morphologic LVNC population is strongly associated with adverse clinical events. LVNC is associated with increased trabeculations of the RV apex.

Current limitations of transcatheter aortic valve replacement include paravalvular aortic regurgitation (PAR). We hypothesized that there are varying propensities for location of PAR in the Medtronic CoreValve and the Edwards Sapien Valve. The secondary goal was to longitudinally evaluate PAR

Papillary fibroelastoma (PFE) is a rare benign tumor that most commonly involves heart valves. Cardiac PFE involving the mitral chorda is rarer. Most papillary PFE are asymptomatic; rarely, they are diagnosed because of cardiac symptoms or after an embolic event. In this case, a 70-year-old woman presented with an acute cerebral ischemic infarct. Evaluation for potential embolic source revealed a mass on the mitral chordae. The findings of cardiac magnetic resonance (CMR) tissue characterization of the mass corroborated the diagnosis of mitral valve tumor. She underwent surgical resection of this mass and histology, which confirmed a PFE.