International diagnostic criteria for acute myocardial infarction and acute stroke☆

Rates of cardiovascular disease (CVD) among American Indians (AI) have been increasing. Although we have observed an association between atherosclerosis and CVD in older adults, the potential association among young AI is unclear. Therefore, we aim to describe the prevalence of atherosclerosis among young AI and determine its association with CVD and all-cause mortality.

We evaluated AI participants from the Strong Heart Family Study (SHFS), who were <40 years old and CVD free at the baseline examination, 2001–2003 (n = 1376). We used carotid ultrasound to detect baseline atherosclerotic plaque. We identified CVD events and all-cause mortality through 2019, with a median follow-up of 17.8 years. We used shared frailty Cox Proportional Hazards models to assess the association between atherosclerosis and time to CVD event or all-cause mortality, while controlling for covariates.

Among 1376 participants, 71 (5.2%) had atherosclerosis at baseline. During follow-up, 120 (8.7%) had CVD events and 104 (7.6%) died from any cause. CVD incidence was higher in participants who had baseline atherosclerosis (13.51/1000 person-years) than in those who did not (4.95/1000 person-years, p = 0.0003). CVD risk and all-cause mortality were higher in participants with atherosclerosis, while controlling for covariates (CVD HR = 1.85, 95%CI = 1.02–3.37, p = 0.0420; all-cause mortality HR = 2.04, 95%CI = 1.07–3.89, p = 0.0291).

Among young AI, atherosclerosis was independently associated with incident CVD and all-cause mortality later in life. Thus, atherosclerosis begins early in life and interventions in adolescents and young adults to slow the progression of disease could prevent or delay CVD events later in life.

The measurement of cardiac troponin (cTn) by a high sensitivity method now represents the standard method for cTn measurement in the laboratory. High sensitivity method are not measuring a novel form of troponin but have undergone methodological improvement in assay sensitivity to allow both very low level detection and repeat measurements at low levels with very low degrees of analytical imprecision. The methods identify additional patients with myocardial injury who would benefit from evidence-based interventions. Rapid predictive algorithms utilising measurement on admission as well as short sampling periods (1–2 h) allow much more rapid categorisation of patients to appropriate clinical pathways. The shift in the diagnosis from traditional “cardiac enzymes” to troponin based on the 99th percentile has accounted for the majority of the detection of myocardial injury in patients without acute coronary syndromes. These patients have a worse prognosis irrespective of the underlying cause of their hospital admission. The appropriate management strategy in this group, beyond managing the underlying problem, remains to be defined. Measurement of cTn in otherwise asymptomatic individuals may have a role for patient selection for preventive treatment or for patients monitoring. Clinical trials in this area are awaited.

Von Willebrand factor (VWF) elevation correlates with the left atrial blood stasis in nonvalvular atrial fibrillation (NVAF). However, the long-term impact of elevated VWF in patients with NVAF is not well established.

To assess the impact of VWF and a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) in conjunction with echocardiographic measures of left atrium blood stasis on clinical outcomes, 414 NVAF prospectively recruited (October 4, 2007, to April 27, 2009) patients were followed for 3 years. VWF antigen, VWF activity, ADAMTS13 activity, and echocardiographic findings were assessed at baseline. Thromboembolism (TE) (stroke/transient ischemic attack (TIA)), myocardial infarction, or TE of other locations), major bleeding, clinically relevant nonmajor bleeding, and all-cause mortality were assessed by clinical follow-up, questionnaire, or telephone communication.

Among 374 patients (mean age, 63.4 ± 12.7 years; 25% females) who had complete follow-up data, there were 33 TE in 32 patients (8.6%), 18 deaths (5.1%), and 33 bleeding events (21 major bleeding and 12 clinically relevant nonmajor bleeding) in 25 patients (6.7%). VWF antigen was predictive of TE in the univariate examination (hazard ratio [HR]: 1.007, 95% confidence interval [CI]: 1.002, 1.013, P = 0.011) but not in multivariate analysis. VWF was an independent predictor of all-cause mortality (HR: 1.011, 95% CI: 1.003, 1.020, P = 0.011) and a composite of TE and all-cause mortality (HR: 1.006, 95% CI: 1.001, 1.012, P = 0.039) in multivariate analysis. ADAMTS13 was not predictive of clinical outcomes in multivariate analysis.

Among patients with NVAF, VWF is an independent predictor of poor outcomes including death and a composite of death and TE. As such, VWF measure may help identify high-risk patients and provide further stratification beyond CHA₂DS₂-VASc assessment.

Une élévation du facteur de Von Willebrand (FVW) concorde avec une stase sanguine dans l'oreillette gauche dans la fibrillation auriculaire non valvulaire (FANV). Les répercussions à long terme d'un taux élevé du FVW chez les patients présentant une FANV ne sont toutefois pas bien établies.

Pour évaluer les répercussions sur les résultats cliniques du FVW et d'une désintégrine et métalloprotéinase de motif type 1 (ADAMTS13) conjointement avec les mesures échocardiographiques de la stase sanguine dans l'oreillette gauche, 414 patients atteints de FANV ont été inscrits de façon prospective (du 4 octobre 2007 au 27 avril 2009) pour faire l'objet d'un suivi de 3 ans. L'antigène du FVW, l'activité du FVW, l'activité d'ADAMTS13, et les résultats de l'échocardiographie ont été évalués au départ. La thromboembolie (TE) (accident vasculaire cérébral/accident ischémique transitoire, infarctus du myocarde, ou TE survenant ailleurs), l'hémorragie majeure, l'hémorragie non majeure pertinente sur le plan clinique et la mortalité toutes causes ont été évaluées au suivi clinique, par questionnaire, ou lors d'un appel téléphonique.

Parmi les 374 patients (âge moyen : 63,4 ± 12,7 ans; 25 % de femmes) ayant participé au suivi jusqu'à sa fin, on a relevé 33 TE chez 32 patients (8,6 %), 18 décès (5,1 %) et 33 événements hémorragiques (21 hémorragies majeures et 12 hémorragies non majeures pertinentes sur le plan clinique) chez 25 patients (6,7 %). L'antigène du FW était prédictif d'une TE selon l'analyse univariée (risque relatif [RR] : 1,007; intervalle de confiance [IC] à 95 % : de 1,002 à 1,013; p = 0,011), mais non selon l'analyse multivariée. Le FVW était un facteur prédictif indépendant de la mortalité toutes causes (RR : 1,011; IC à 95 % : de 1,003 à 1,020; p = 0,011) et des événements regroupés de TE et de mortalité toutes causes (RR : 1,006; IC à 95 % : de 1,001 à 1,012; p = 0,039) dans l'analyse multivariée. La protéase ADAMTS13 ne constituait pas un facteur prédictif des résultats cliniques dans l'analyse multivariée.

Parmi les patients présentant une FANV, le FVW était un facteur prédictif indépendant de résultats défavorables, notamment de décès et des événements regroupant les décès et la TE. La mesure du FVW pourrait donc aider à cibler les patients à risque élevé, et permettre une stratification au-delà de l'évaluation du score CHA₂DS₂-VASc.

Sleep-disordered breathing (SDB) is highly prevalent after stroke and is associated with poor outcomes. Currently, after stroke, objective testing must be used to differentiate patients with and without SDB. Within a large, population-based study, we evaluated the usefulness of a flexible statistical model based on baseline characteristics to predict post-stroke SDB.

Within a population-based study, participants (2010–2018) underwent SDB screening, shortly after ischemic stroke, with a home sleep apnea test. The respiratory event index (REI) was calculated as the number of apneas and hypopneas per hour of recording; values ≥10 defined SDB. The distributed random forest classifier (a machine learning technique) was applied to predict SDB with the following as predictors: demographics, stroke risk factors, stroke severity (NIHSS), neck and waist circumference, palate position, and pre-stroke symptoms of snoring, apneas, and sleepiness.

Within the total sample (n = 1330), median age was 65 years; 47% were women; 32% non-Hispanic white, 62% Mexican American, and 6% African American. SDB was found in 891 (67%). The area under the receiver operating characteristic curve, a measure of predictive ability, applied to the validation sample was 0.75 for the random forest model. Random forest correctly classified 72.5% of validation samples.

In this large, ethnically diverse, population-based sample of ischemic stroke patients, prediction models based on baseline characteristics and clinical measures showed fair rather than clinically reliable performance, even with use of advanced machine learning techniques. Results suggest that objective tests are still needed to differentiate ischemic stroke patients with and without SDB.

To compare the frequency of and trends in hospitalizations after heart failure (HF) diagnosis in patients with and without rheumatoid arthritis (RA) during 1987–2015.

The study included a retrospectively identified population-based cohort of patients with incident HF and prior RA (age≥18 years, 1987 ACR criteria) and a cohort of incident HF patients without RA matched 3:1 on age, sex, and year of HF diagnosis. Hospitalizations at the time of HF diagnosis were excluded. All subjects were followed until death, migration, or 12/31/2015.

The study included 212 patients with RA (mean age at HF diagnosis 78.3 years; 68% female) and 636 non-RA patients (mean age at HF diagnosis 78.6 years; 68% female). The hospitalization rate after HF diagnosis was higher in RA vs non-RA (rate ratio [RR] 1.17; 95%CI 1.08-1.26). Hospitalization rates in both groups have been declining since 2005 and the difference between patients with and without RA may be decreasing after 2010. The magnitude of the increase was similar in both sexes and across all ages. Patients with RA were more likely to be hospitalized for non-cardiovascular causes (RR 1.26; 95%CI 1.14-1.39), but not for HF or other cardiovascular causes compared to non-RA patients.

The hospitalization rate following HF diagnosis was higher in RA versus non-RA patients regardless of sex and age. Increased hospitalization risk in patients with RA was driven by increased rates of non-cardiovascular hospitalization.

To delineate the impact of diabetes mellitus (DM) on the development of cardiovascular diseases in a community population.

Cross-sectional survey of residents randomly selected through the Rochester Epidemiology Project, 45 years or older, of Olmsted County as of June 1, 1997, through September 30, 2000. Responders (2042) underwent assessment of systolic and diastolic function using echocardiography. The current analyses included all participants with DM and were compared with a group of participants without DM matched 1:2 for age, sex, hypertension, and coronary artery disease. Baseline characteristics and laboratory and echocardiography findings between groups were compared along with rates of mortality due to various cardiovascular conditions.

We identified 116 participants with DM and 232 matched participants without DM. Those with DM had a higher body mass index and plasma insulin and serum glucose levels. Although left ventricular ejection fractions were similar, E/e' ratio (9.7 vs 8.5; P=.001) was higher in DM vs non-DM. During a follow-up of 10.8 (interquartile range, 7.8-11.7) years, participants with DM had a higher incidence of heart failure (HF); hazard ratio, 2.1; 95% confidence limits, 1.2-3.6; P=.01) and 10-year Kaplan-Meier rate of 21% (22 of 116) vs 12% (24 of 232) compared with those without DM. We also examined the subgroup of participants without diastolic dysfunction. In this subgroup, those with DM had an increased risk for HF; hazard ratio, 2.5; 95% confidence limits, 1.0-6.3; P=.04).

In this cohort, participants with DM have an increased incidence of HF over a 10-year follow-up period even in the absence of underlying diastolic dysfunction. These findings suggest that DM is an independent risk factor for the development of HF and supports the concept of DM cardiomyopathy.