by
Joyce T. Johnson;
Lynn A. Sleeper;
Shan Chen;
Richard G. Ohye;
Michael G. Gaies;
Ismee A. Williams;
Ritu Sachdeva;
Jay D. Pruetz;
Gregory H. Tatum;
Deepika Thacker;
Marissa A. Brunetti;
Michele A. Frommelt;
Jeffrey P. Jacobs;
Joel A. Kirsh;
Linda M. Lambert;
Jane W. Newburger;
Victoria L. Pemberton;
Sinai C. Zyblewski;
Allison A. Divanovic;
Nelangi M. Pinto
Newborns with hypoplastic left heart syndrome and other single right ventricular variants require substantial health care resources. Weekend acute care has been associated with worse outcomes and increased resource use in other populations but has not been studied in patients with single ventricle. Subjects of the Single Ventricle Reconstruction trial were classified by whether they had a weekend admission and by day of the week of Norwood procedure. The primary outcome was hospital length of stay (LOS); secondary outcomes included transplant-free survival, intensive care unit (ICU) LOS, and days of mechanical ventilation. The Student's t test with log transformation and the Wilcoxon rank-sum test were used to analyze associations. Admission day was categorized for 533 of 549 subjects (13% weekend). The day of the Norwood was Thursday/Friday in 39%. There was no difference in median hospital LOS, transplant-free survival, ICU LOS, or days ventilated for weekend versus non-weekend admissions. Day of the Norwood procedure was not associated with a difference in hospital LOS, transplant-free survival, ICU LOS, or days ventilated. Prenatally diagnosed infants born on the weekend had lower mean birth weight, younger gestational age, and were more likely to be intubated but did not have a difference in measured outcomes. In conclusion, in this cohort of patients with single right ventricle, neither weekend admission nor end-of-the-week Norwood procedure was associated with increased use of hospital resources or poorer outcomes. We speculate that the complex postoperative course following the Norwood procedure outweighs any impact that day of admission or operation may have on these outcomes.
We previously reported that ranolazine improves exercise myocardial perfusion. Ranolazine ameliorates myocardial ischemia by augmenting myocardial blood flow; likely by a reduction in the extravascular compression of small vessels. We hypothesized that ranolazine could improve left ventricular (LV) dyssynchrony as assessed by phase analysis of gated single photon emission computed tomographic myocardial perfusion imaging. Patients (n = 32) with known or suspected coronary artery disease and reversible perfusion defects on a clinically indicated stress myocardial perfusion imaging were restudied 4 weeks after ranolazine (500 to 1,000 mg orally twice daily) was added to their conventional treatment in an open-label trial (data previously reported). The LV systolic and diastolic dyssynchrony indexes were obtained using automated phase analysis before and after ranolazine. No significant changes were found in the heart rate or blood pressure (at rest or during stress) after treatment. The perfusion pattern improved in 13 of 18 patients who had undergone exercise testing, but in only 3 of 14 patients who had undergone vasodilator stress testing. No significant changes were seen in the LV ejection fraction or volume after treatment. The systolic and diastolic LV dyssynchrony improved after ranolazine therapy; there was a significant decrease in the systolic phase SD (21 ± 17 vs 18 ± 13, p = 0.04), systolic bandwidth (69 ± 60 vs 53 ± 38, p = 0.03), diastolic SD (29 ± 18 vs 24 ± 15, p = 0.047) and diastolic bandwidth (91 ± 61 vs 72 ± 45, p = 0.02). In conclusion, the present study is the first to show improvements in diastolic and systolic LV synchrony with ranolazine as measured by automated phase analysis of gated single photon emission computed tomographic myocardial perfusion imaging.
In patients with heart failure (HF), mortality is lower in women versus men. However, it is unknown whether the survival advantage in women compared with men is present in both whites and African Americans with HF. The inception cohort consisted of adults ≥65 years with incident HF after enrollment in the CHS, a prospective population-based study of cardiovascular disease. Of 5,888 CHS subjects, 1,264 developed new HF and were followed up for 3 years. Subjects were categorized into 4 race-gender groups, and Cox proportional hazard regression models were used to examine whether 3-year total and cardiovascular mortality differed among the 4 groups after adjusting for sociodemographic factors, co-morbidities, and treatment. A gender-race interaction was also tested for each outcome. In subjects with incident HF, African Americans had more hypertension and diabetes than whites, and white men had more coronary heart disease than other gender-race groups. Receipt of cardiovascular treatments among the 4 groups was similar. Mortality rates after HF were lower in women compared with men (for white women, African-American women, African-American men, and white men, total mortality was 35.5, 33.6, 44.4, and 40.5/100 person-years, and cardiovascular mortality was 18.4, 19.5, 20.2, and 22.7/100 person-years, respectively). After adjusting for covariates, women had a 15% to 20% lower risk of total and cardiovascular mortality compared with men, but there was no significant difference in outcome by race. The gender-race interaction for either outcome was not significant. In conclusion, in older adults with HF, women had significantly better survival than men irrespective of race, suggesting that gender-based survival differences may be more important than race-based differences.
QT prolongation in the setting of QRS>120 ms is believed to be triggered by prolonged depolarization rather than repolarization. Hence, JT interval is suggested as an alternative to QT interval when QRS duration is prolonged. It is unclear, however, if JT and QT intervals portend similar risk of mortality for different durations of QRS. We examined the association between QT and JT, separately, with all-cause mortality across different levels of QRS duration in 8,025 participants (60±13 years, 41% white, and 54% women) from the Third National Health and Nutrition Examination Survey. At baseline (1986–1994), 486 (6%) participants had QRS duration≥120 ms. During a follow-up of up to 18 years, 3,045 (38%) deaths occurred. There were significant non-linear relationships of QT and JT intervals with mortality (p <0.001). Hence, QT and JT were categorized as prolonged (>95th percentile), shortened (<5th percentile) and normal (reference group). In multivariate adjusted Cox regression models, prolonged JT [HR (95% CI): 4.75, (1.86, 12.11)] was associated with increased risk of mortality more than prolonged QT [HR (95%CI):1.50 (1.03, 2.17)] in participants with QRS ≥120 ms (Interaction p=0.02). In participants with QRS duration <120ms, prolonged QT and JT were equally predictive of all-cause mortality [HR (95%CI): 1.27(1.06, 1.54)] and [1.31 (1.10, 1.55)], respectively. Similar patterns were observed with shortened QT and JT intervals. In conclusion, although both QT and JT intervals are predictive of mortality, JT is more predictive in the setting of QRS duration>120 ms supporting the use of JT interval in individuals with prolonged QRS.
The pooled cohort Atherosclerotic Cardiovascular Disease (ASCVD) risk calculator is designed to improve cardiovascular risk estimation compared with the Framingham Risk Score, particularly in blacks. Although the ASCVD risk score better predicts mortality and incident cardiovascular disease in blacks, less is known about its performance for subclinical vascular disease measures, including arterial stiffness and carotid intima-media thickness. We sought to determine if the ASCVD risk score better identifies subclinical vascular disease in blacks compared with the Framingham risk score. We calculated both the Framingham and ASCVD cohort risk scores in 1,231 subjects (mean age 53 years, 59% female, 37% black) without known cardiovascular disease and measured the extent of arterial stiffness, as determined by pulse wave velocity (PWV), central pulse pressure (CPP), and central augmentation index (CAIx), and subclinical atherosclerosis, as determined by carotid-IMT (C-IMT). Compared with whites, blacks had higher CAIx (23.9 ± 10.2 vs 22.1 ± 9.6%, p = 0.004), CPP (36.4 ± 10.5 vs 34.9 ± 9.8 mmHg, p = 0.014), PWV (7.6 ± 1.5 vs 7.3 ± 1.3 m/s, p = 0.004), and C-IMT (0.67 ± 0.10 vs 0.65 ± 0.10 mm, p = 0.005). In a multivariable analysis including race and Framingham risk score, race remained an independent predictor of all measures of subclinical vascular disease; however, models with race and the ASCVD risk score showed that race was not an independent predictor of subclinical vascular disease. In conclusion, greater subclinical vascular disease in blacks was not estimated by the Framingham risk score. The new ASCVD risk score provided a better estimate of racial differences in vascular function and structure.
The lack of abnormalities found on noninvasive cardiac testing possibly improves cardiovascular disease (CVD) risk stratification efforts and conveys reduced risk despite the presence of traditional risk factors. This analysis included 3,805 (95% white and 61% women) participants from the Cardiovascular Health Study (CHS) without baseline CVD. The combination of a normal electrocardiogram (ECG) and echocardiogram was assessed for the development of CVD. A normal ECG was defined as the absence of major or minor Minnesota code abnormalities. A normal echocardiogram was defined as the absence of contractile dysfunction, wall motion abnormalities, or abnormal left ventricular mass. Cox regression was used to compute the 10-year risk of developing coronary heart disease, stroke, and heart failure events. There were 1,555 participants (41%) with normal findings on both measures. After accounting for traditional CVD risk factors, a protective benefit was observed for all outcomes among participants who had normal ECG and echocardiographic findings (coronary heart disease: hazard ratio [HR] 0.56, 95% confidence interval [CI] 0.46, 0.69; stroke: HR 0.57, 95% CI 0.43, 0.76; heart failure: HR 0.36, 95% CI 0.29, 0.41). The addition of this normal profile resulted in significant net reclassification improvement of the Framingham risk score for heart failure (net reclassification improvement 4.3%, 95% CI 1.0, 8.0). In conclusion, normal findings on routine noninvasive cardiac assessment identify subjects in whom CVD risk is low.
Reports on the association between the PR-interval and atrial fibrillation (AF) are conflicting. We hypothesized that inconsistencies stem from that fact that the PR-interval represents a composite of several distinct components. We examined the associations of the PR-interval and its components (P-wave onset to P-wave peak duration, P-wave peak to P-wave end duration, and PR-segment) with incident AF in 14,924 participants (mean age 54 ± 5.8 years; 26% black; 55% women) from the Atherosclerosis Risk In Communities study. The PR-interval and its components were automatically measured at baseline (1987 to 1989) from standard 12-lead electrocardiograms. PR-interval > 200 ms was considered prolonged and values above the ninety-fifth percentile defined abnormal PR-interval components. AF was ascertained during follow-up through December 31, 2010. Over a median follow-up of 21.2 years, 1,985 participants (13%) developed AF. Prolonged PR-interval was associated with an increased risk of AF (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.02 to 1.40). However, PR-interval components showed varying levels of association with AF (P-wave onset to P-wave peak duration: HR 1.57, 95% CI 1.31 to 1.88; P-wave peak to P-wave end duration: HR 1.20, 95% CI 0.99 to 1.46; and PR-segment: HR 1.05, 95% CI 0.85 to 1.29). In addition, the components of the PR-interval had weak-to-moderate correlation with each other (correlation r ranged from −0.44 to 0.06). In conclusion, our findings suggest the PR-interval represents a composite of distinct components that are not uniformly associated with AF. Without considering the contribution of each component, inconsistent associations between the PR-interval and AF are inevitable.