Chronotropic incompetence and long-term risk of heart failure: The henry ford exercise testing project

Background: Chronotropic incompetence (CI) has been associated with cardiovascular mortality. However, its relationship with long-term risk of heart failure (HF) is not well studied. Methods: We included 43,098 participants (mean age 51.7±12.3 years, 47.5% females, 66.6% white) of the FIT project who completed a clinically indicated exercise test between 1991 and 2009. Patients with coronary artery disease, prior HF or on heart rate reducing medications were excluded. Incident HF was defined by having a documented diagnosis in 3 separate clinical encounters. CI was defined by inability to achieve 85% of maximal age predicted heart rate (calculated by 220 - age) with exercise. Multivariable adjusted Cox models were used to assess the independent association of CI with incident HF. Results: At baseline, 5,249 (12.2%) had CI. After a mean follow-up duration of 10.9 ± 4.6 years, 1329 (3.2%) experienced new onset HF. The cumulative incidence of HF was 397 (7.6%) among CI patients compared with 992 (2.6%) among chronotropic competent patients. Figure 1 shows the cumulative incidence of heart failure by CI status. In multivariable Cox regression models, CI was associated with increased risk of incident heart failure (HR 1.73; 95% CI 1.48 – 2.03, p \u3c0.001) after adjusting for confounders. There were no interactions by age, sex, race, body mass index. Conclusions: Our study shows that CI is an independent risk factor for HF. Further research is needed to determine whether CI could be a therapeutic target for HF

Eighty-two-year-old man with a systolic murmur

CLINICAL INTRODUCTION: An 82-year-old man with a history of coronary artery bypass surgery, hypertension and small bowel gastrointestinal stromal tumour underwent cardiac risk evaluation prior to surgical resection of his tumour. He was asymptomatic from a cardiovascular perspective, but his activity level was less than four metabolic equivalents. Physical examination was notable for a 2/6 systolic murmur at the apex. ECG showed sinus rhythm. A transthoracic echocardiogram was performed (figure 1 and online supplementary video 1).DC1SP110.1136/heartjnl-2018-313413.supp1Supplementary file 1 heartjnl;104/22/1887/F1F1F1Figure 1Transthoracic echocardiography. (A) Mitral valve continuous wave Doppler and (B) tricuspid valve continuous wave Doppler. QUESTION: The findings in figure 1 are most likely due to which of the following?Atrioventricular conduction block.Acute severe aortic regurgitation.Patent ductus arteriosus.Atrial flutter.Severe mitral stenosis

An unusual ECG deflection: Fact or artifact?

Peculiar electrocardiographic findings are not unusual and upon careful review can often be clarified. We present a case of an 85year-old woman with no previous cardiac history, incidentally discovered high grade atrioventricular block, and a puzzling electrocardiographic complex of unclear etiology which defies reasonable physiological explanations. The finding resembled a tiny QRS in a perfectly regular R-R interval following only non-conducted P-waves. The patient declined further work-up, so a definite cause could not be determined, but based on history, complex morphology, and inability to reproduce or explain the findings, we were compelled to accept the finding as an artifact

A Rare Case of Aspergillus Pericarditis with Associated Myocardial Abscess and Echocardiographic Response to Therapy

Myocardial abscess is an extremely rare entity and is often deadly in nature. We present a case of a patient with recent orthotopic liver transplant, on immunosuppression, who presented with cardiac tamponade due to Aspergillus fumigatus pericarditis and associated myocardial abscess. The diagnosis was made based on computed tomography imaging, culture of pericardial fluid for Aspergillus, and transthoracic echocardiography. The patient received antifungal therapy with clinical improvement and documented reduction in abscess size based on repeat echocardiogram. Aspergillus myocardial abscess is an extremely rare diagnosis but should be considered in an immunosuppressed patient presenting with pericardial effusion or ventricular mass

Mechanisms of cardiac collagen deposition in experimental models and human disease

The inappropriate deposition of extracellular matrix within the heart (termed cardiac fibrosis) is associated with nearly all types of heart disease, including ischemic, hypertensive, diabetic, and valvular. This alteration in the composition of the myocardium can physically limit cardiomyocyte contractility and relaxation, impede electrical conductivity, and hamper regional nutrient diffusion. Fibrosis can be grossly divided into 2 types, namely reparative (where collagen deposition replaces damaged myocardium) and reactive (where typically diffuse collagen deposition occurs without myocardial damage). Despite the widespread association of fibrosis with heart disease and general understanding of its negative impact on heart physiology, it is still not clear when collagen deposition becomes pathologic and translates into disease symptoms. In this review, we have summarized the current knowledge of cardiac fibrosis in human patients and experimental animal models, discussing the mechanisms that have been deduced from the latter in relation to the former. Because assessment of the extent of fibrosis is paramount both as a research tool to further understanding and as a clinical tool to assess patients, we have also summarized the current state of noninvasive/minimally invasive detection systems for cardiac fibrosis. Albeit not exhaustive, our aim is to provide an overview of the current understanding of cardiac fibrosis, both clinically and experimentally

4D Flow MRI Quantification of Congenital Shunts: Comparison to Invasive Catheterization

PurposeTo compare invasive right heart catheterization with four-dimensional (4D) flow MRI for estimating shunt fraction in patients with intracardiac and extracardiac shunts.Materials and methodsIn this retrospective study, patients who underwent 4D flow MRI and invasive right heart catheterization with a shunt run between August 2015 and November 2018 were included. The primary objective was comparison of estimated shunt fraction (ratio of pulmonary-to-systemic flow, Qp/Qs) at 4D flow and catheterization. Secondary objectives included comparison of the right ventricular-to-left ventricular stroke volume ratio (RVSV/LVSV) to shunt fraction (for those with applicable shunts) and comparison of cardiac output between 4D flow and catheterization. Statistical analysis included Pearson correlation and Bland-Altman plots.ResultsA total of 33 patients met inclusion criteria (mean age, 49 years ± 16 [standard deviation]; 24 women). 4D flow measurements of Qp/Qs strongly correlated with those at catheterization (r = 0.938), and there was no bias. RVSV/LVSV correlated strongly with Qp/Qs from 4D flow (r = 0.852) and catheterization (r = 0.842). Measurements of left ventricle (Qs) and right ventricle (QP) cardiac output from 4D flow and catheterization (Fick) correlated moderately overall (r = 0.673 [Qp] and r = 0.750 [Qs]).ConclusionShunt fraction measurement using 4D flow MRI compares well with that using invasive cardiac catheterization.Supplemental material is available for this article.© RSNA, 2021

Design of movables Weirs and Storm Surge Barriers

State of of in the dsign of movable weirs and storm surge barriersINCO

Socioeconomic Disparities in Access for Watchman Device Insertion in Patients with Atrial Fibrillation and at Elevated Risk of Bleeding

Background: As the Watchman device is new, no studies have yet reported on healthcare disparity issues in this population. We sought to investigate socioeconomic and racial disparities among select atrial fibrillation (AF) patients who did or did not receive Watchman device placement. Methods: This retrospective case-control study included patients with non-valvular AF requiring long-term anticoagulation who underwent left atrial appendage (LAA) exclusion with the Watchman device at our institution from June 2015 to December 2016. A control group was designed by medical records query for patients with non-valvular AF requiring long-term anticoagulation with an elevated risk of bleeding (defined by hospital admission for major bleeding episodes and discharged off anticoagulation), but not referred for LAA closure within the study period. Differences in median income, type of insurance coverage, race, sex, and age were analyzed. Results: Of 201 patients, 98 received the Watchman device (intervention) and 103 did not (control). The mean estimated income was significantly higher for intervention than control patients ($70,908.50 ±$25,847.20 vs. $56,569.90 ±$17,730.90; p \u3c 0.001). African-American patients were less likely to receive the Watchman insertion (5% vs. 27%; p \u3c 0.001). Control patients had a higher percentage with Medicaid by both primary (6% vs. 0; p = 0.029) and dual coverage of Medicare and Medicaid (13% vs. 4%; p = 0.041). No significant difference occurred in gender. Conclusion: Socioeconomic and racial disparities exist in patients with non-valvular AF at elevated risk of bleeding. African-American patients with lower income and Medicaid are less likely to be referred for the Watchman device

Socioeconomic Disparities in Access for Watchman Device Insertion in Patients with Atrial Fibrillation and at Elevated Risk of Bleeding

Background: As the Watchman device is new, no studies have yet reported on healthcare disparity issues in this population. We sought to investigate socioeconomic and racial disparities among select atrial fibrillation (AF) patients who did or did not receive Watchman device placement. Methods: This retrospective case-control study included patients with non-valvular AF requiring long-term anticoagulation who underwent left atrial appendage (LAA) exclusion with the Watchman device at our institution from June 2015 to December 2016. A control group was designed by medical records query for patients with non-valvular AF requiring long-term anticoagulation with an elevated risk of bleeding (defined by hospital admission for major bleeding episodes and discharged off anticoagulation), but not referred for LAA closure within the study period. Differences in median income, type of insurance coverage, race, sex, and age were analyzed. Results: Of 201 patients, 98 received the Watchman device (intervention) and 103 did not (control). The mean estimated income was significantly higher for intervention than control patients ($70,908.50 ±$25,847.20 vs. $56,569.90 ±$17,730.90; p \u3c 0.001). African-American patients were less likely to receive the Watchman insertion (5% vs. 27%; p \u3c 0.001). Control patients had a higher percentage with Medicaid by both primary (6% vs. 0; p = 0.029) and dual coverage of Medicare and Medicaid (13% vs. 4%; p = 0.041). No significant difference occurred in gender. Conclusion: Socioeconomic and racial disparities exist in patients with non-valvular AF at elevated risk of bleeding. African-American patients with lower income and Medicaid are less likely to be referred for the Watchman device