Ada C. Stefanescu Schmidt

Sex Differences in Faculty Rank Among Academic Cardiologists in the United StatesClinical Perspective

Background: Studies demonstrate that women physicians are less likely than men to be full professors. Comprehensive evidence examining whether sex differences in faculty rank exist in academic cardiology, adjusting for experience and research productivity, is lacking. Therefore, we evaluated for sex differences in faculty rank among a comprehensive, contemporary cohort of US cardiologists after adjustment for several factors that impact academic advancement, including measures of clinical experience and research productivity. Methods: We identified all US cardiologists with medical school faculty appointments in 2014 by using the American Association of Medical Colleges faculty roster and linked this list to a comprehensive physician database from Doximity, a professional networking website for doctors. Data on physician age, sex, years since residency, cardiology subspecialty, publications, National Institutes of Health grants, and registered clinical trials were available for all academic cardiologists. We estimated sex differences in full professorship, adjusting for these factors and medical school–specific fixed effects in a multivariable regression model. Results: Among 3810 cardiologists with faculty appointments in 2014 (13.3% of all US cardiologists), 630 (16.5%) were women. Women faculty were younger than men (mean age, 48.3 years versus 53.5 years, P<0.001), had fewer total publications (mean number: 16.5 publications versus 25.2 publications; P<0.001), were similarly likely to have National Institutes of Health funding (proportion with at least 1 National Institutes of Health award, 10.8% versus 10.4%; P=0.77), and were less likely to have a registered clinical trial (percentage with at least 1 clinical trial, 8.9% versus 11.1%; P=0.10). Among 3180 men, 973 (30.6%) were full professors in comparison with 100 (15.9%) of 630 women. In adjusted analyses, women were less likely to be full professors than men (adjusted odds ratio, 0.63; 95% confidence interval, 0.43–0.94; P=0.02; adjusted proportions, 22.7% versus 26.7%; absolute difference, –4.0%; 95% confidence interval, –7.5% to –0.7%). Conclusions: Among cardiology faculty at US medical schools, women were less likely than men to be full professors after accounting for several factors known to influence faculty rank.

Treatment of Hypertension in Coarctation of the Aorta

Opinion statementThe treatment of hypertension in coarctation of the aorta (CoA) is ideally managed by early surgical or transcatheter repair to reduce the risk of irreversible aortopathy and refractory hypertension, in addition to other associated sequelae including premature coronary artery disease; stroke; aortic aneurysm, dissection, and rupture; infective endocarditis; and heart failure. The choice of surgical or transcatheter repair is dependent on individual patient considerations. Medical therapy for hypertension due to CoA parallels treatment of essential hypertension with beta blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers as first-line agents.

Myocardial Infarction Risk After Discontinuation of Thienopyridine Therapy in the Randomized DAPT Study (Dual Antiplatelet Therapy)Clinical Perspective

Background: Thienopyridine plus aspirin beyond 1 year after coronary stenting reduces myocardial infarction (MI) risk and increases bleeding risk in comparison with aspirin alone. The hazard associated with late thienopyridine discontinuation and risk factors for MI after discontinuation are poorly defined. Methods: In the DAPT Study (Dual Antiplatelet Therapy), after percutaneous coronary intervention and 12 months of thienopyridine (clopidogrel or prasugrel) plus aspirin, eligible patients remained on aspirin and were randomly assigned to continued thienopyridine versus placebo for 18 months. At 30 months, patients stopped the study drug and were observed for 3 months. Cumulative incidence of MI was assessed over 3 months after randomization (months 12–15) and 3 months after study drug discontinuation (months 30–33). The MI hazard for each of these periods was assessed across randomized treatment arms and by DAPT score values <2 or ≥2. Results: Among the 11 648 randomly assigned patients, the monthly cumulative incidence of MI was lower with continued thienopyridine versus placebo at 12 to 15 months (0.12% versus 0.37%, P<0.001, in all patients; 0.13% versus 0.27%, P=0.02, in patients not treated with paclitaxel-eluting stents), and higher at 30 to 33 months (0.30% versus 0.15%, P=0.013, in all patients; in patients without paclitaxel-eluting stents, 0.18% versus 0.17%, P=0.91). The majority of MIs in both time periods (74% and 76%) were not related to stent thrombosis. After multivariable adjustment, treatment arm independently predicted MI at months 12 to 15 (P<0.001) and 30 to 33 (P=0.011). During months 12 to 15, patients with DAPT scores <2 or ≥2 both had lower rates of MI with continued thienopyridine (MI monthly incidence 0.16% versus 0.51%, P<0.001, for scores ≥2; 0.08% versus 0.24%, P=0.012, for scores<2, interaction P=0.064). Conclusions: Discontinuing thienopyridine after either 12 or 30 months is associated with an early increase in MI risk, mainly unrelated to stent thrombosis; the magnitude of risk is highest in the earlier time frame, and lower in patients not treated with paclitaxel-eluting stents. Although higher DAPT scores identify patients with greater absolute ischemic benefit (relative to bleeding harm) with continued thienopyridine therapy, discontinuation at 12 months increases MI hazard regardless of DAPT score group. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00977938.

Prediction of adverse events after catheter-based procedures in adolescents and adults with congenital heart disease in the IMPACT registry

Aims We sought to identify factors associated with major adverse events (MAE) after cardiac catheterization in adolescents and adults with congenital heart disease (CHD), and create the first model to individualize risk discussions in this growing population. Methods and results Improving Pediatric and Adult Congenital Treatment (IMPACT), a National Cardiovascular Data Registry, contains congenital catheterization data from over 87 hospitals in the United States. Demographics, pre-procedure, and procedural variables were collected for patients over age 10. Multivariable logistic regression was used to identify significant predictors of MAE, a composite of death, urgent surgery or procedure due to a catheterization complication, transfusion, embolic stroke, tamponade, extracorporeal membrane oxygenation or ventricular assist device placement, and device embolization, malposition or thrombosis requiring surgical intervention. A risk score was built based on the effect sizes of each predictor and validated in a split sample. A MAE occurred in 686 (2.5%) of the 27 293 index procedures meeting inclusion criteria. The independent multivariate predictors of MAE were older age, pre-procedural anticoagulation use, renal disease, lower haemoglobin, lower oxygen saturation, non-elective procedure, higher index procedure risk and having had no prior cardiac procedures. Being underweight or overweight had borderline significance and was added to the model. The C-statistic for the model was robust at 0.787 in the derivation and 0.773 in the validation cohort. Conclusion The factors predicting adverse events after cardiac catheterization in adolescents and adults with CHD are different than in the general population. Validation of this model in other national or multi-institutional datasets is the next step.

Frequency of Guideline-Based Statin Therapy in Adults With Congenital Heart Disease

We aimed to evaluate atherosclerotic cardiovascular disease (ASCVD) risk estimates and guideline-based statin use for primary prevention of ASCVD in adults with congenital heart disease (ACHD). This was a case-controlled, retrospective study of 248 cases and 744 age- and gender-matched controls at a tertiary care referral center. ASCVD risk scores were calculated and used to assess indication for statin treatment for primary prevention per the 2013 American College of Cardiology and American Heart Association guideline on assessment of cardiovascular risk. There were no differences in average 10-year ASCVD risk scores between ACHD cases (4.6% ± 6.6%) and matched controls (5.1% ± 6.7%, p = 0.32). ACHD cases had lower total cholesterol (183 ± 38 vs 192.6 ± 35.3 mg/dL, p < 0.001) and were less likely to smoke (8.1% vs 14.6%, p = 0.008), yet had lower high density lipoprotein (52.6 ± 17.2 vs 55.3 ± 17.1 mg/dL, p = 0.03) and higher hypertension rates (38.7% vs 28.5%, p = 0.003). However, only 42.3% ACHD cases with a primary prevention statin indication were appropriately prescribed therapy as compared with 59.0% of controls (p = 0.04). In conclusion, ACHD cases have a similar 10-year ASCVD risk score than age- and gender-matched peers, but ACHD cases are less likely than their peers to be prescribed statin therapy for primary prevention per guideline-based recommendations.

Adult Congenital Heart Disease Patients Experience Similar Symptoms of Disease Activity

Background—There is a lack of objective data on the symptoms characterizing disease activity among adults with congenital heart disease (ACHD). The purpose of this study was to elicit the most important symptoms from patients across the spectrum of ACHD and to examine whether reported symptoms were similar across the spectrum of ACHD as a foundation for creating a patient-reported outcome measure(s). Methods and Results—We constructed a 39-item survey using input from physicians specializing in ACHD to assess the symptoms patients associate with disease activity. Patients (n=124) prospectively completed this survey, and the results were analyzed based on underlying anatomy and disease complexity. A confirmatory cohort of patients (n=40) was then recruited prospectively to confirm the validity of the initial data. When grouped based on underlying anatomy, significant differences in disease-related symptom rankings were found for only 6 of 39 symptoms. Six symptoms were identified which were of particular significance to patients, regardless of underlying anatomy. Patients with anatomy of great complexity experienced greater overall symptom severity than those with anatomy of low or moderate complexity, attributable exclusively to higher ranking of 5 symptoms. The second patient cohort had symptom experiences similar to those of the initial cohort, differing in only 5 of 39 symptoms. Conclusions—This study identified 6 symptoms relevant to patients across the spectrum of ACHD and remarkable homogeneity of patient experience, suggesting that a single disease-specific patient-reported outcome can be created for quality and outcome assessments.

Impaired right ventricular reserve predicts adverse cardiac outcomes in adults with congenital right heart disease

Objective The prevalence of heart failure (HF) among adult patients with congenital heart disease (ACHD) is rising. Right ventricle (RV) exercise reserve and its relationship to outcomes have not been characterised. We aim to evaluate the prognostic impact of impaired RV reserve in an ACHD population referred for cardiopulmonary exercise testing (CPET). Methods This retrospective study evaluates patients with ACHD who underwent CPET (n=147) with first-pass radionuclide ventriculography at a single tertiary care centre. RV reserve was categorised as normal, mild to moderately or severely impaired. The primary composite clinical outcome included clinical right HF, arrhythmia, transplantation or death. Results Patients were median age 41±13 years, 50% were female and median follow-up was 1.1 (IQR: 0.7–2.0) years. Exercise RV reserve was impaired in 103 patients (70%), of whom 32% were asymptomatic. Resting RV systolic function poorly predicted RV reserve, with 52% of patients with severe impairment having a qualitatively normal echocardiographic assessment. The severely impaired reserve group had lower peak oxygen consumption (VO2)(17.2 vs 22.5 mL/kg/min, p<0.0001) compared with the normal reserve group, and was more likely to develop the composite outcome (48% vs 9%, log-rank p<0.001). Severely impaired RV reserve predicted event-free survival after adjusting for peak VO2, age, sex, RV pathology, QRS duration, New York Heart Association class, resting RV ejection fraction and RV dilation by echocardiography or MRI (HR 3.7, 95% CI 1.1 to 13.0, p=0.039). Conclusion Impaired RV reserve, occurred in asymptomatic patients, was not well predicted by resting systolic function assessment, and strongly predicted adverse cardiovascular outcomes.

Subclinical Burden of Coronary Artery Calcium in Patients with Coarctation of the Aorta

Coronary computed tomography (CT) angiography is often performed in adults with coarctation of the aorta (CoA) for anatomic assessment. As this population ages, assessment of atherosclerotic cardiovascular disease burden is important. Thus, quantitative and qualitative coronary artery calcium (CAC) scores were assessed for patients with CoA ≥16 years of age, who were seen at a referral center. CoA patients had either coronary CT angiography or chest CT with interpretable coronary information performed for clinical indications (follow-up, preoperative, or for symptoms) from 2004 to 2017. Qualitative CAC was determined based on low-dose CT and lung cancer screening protocols. Quantitative CAC scores were compared with an age- and gender-matched control cohort of patients chosen from an emergency department database of patients who received coronary CT angiography for chest pain evaluation. Atherosclerotic cardiovascular disease 10-year predicted risk scores were calculated for both cohorts. Out of 131 patients with CoA (mean age 46.1 ± 15.3 years), 22 patients (17%) had multivessel atherosclerotic disease on qualitative assessment. In the subgroup of patients ≥40 years, those with CoA were more likely to have a quantitative CAC score ≥400 compared with those without CoA (14% vs 4%, p = 0.02). Median atherosclerotic cardiovascular disease risk score was 8% (interquartile range 2% to 12%) for CoA patients ≥40 years, and 5% (interquartile range 2% to 9%) for patient without CoA ≥40 years. In conclusion, we determined that CoA patients have subclinical atherosclerosis identifiable on CT in high rates when compared with patients without CoA. Atherosclerotic cardiovascular disease should be assessed in these patients for prevention and treatment.

Increasing the evidence base in adult congenital heart disease

Ventricular arrhythmias remain a challenge in the care of adults with congenital heart disease (ACHD). This Heart review1 outlines the current frameworks for arrhythmia management while drawing our attention to the knowledge gaps and opportunities to better inform ourselves about the development, presence and treatment of ventricular arrhythmias in ACHD. The development of evidence-based guidelines in ACHD is particularly difficult for several reasons. Randomised controlled trials (RCTs) provide the foundation of data for most other cardiac guidelines; however, heterogeneity of diagnoses and physiological variations leads to relatively small populations in ACHD, which require long recruitment periods. Today, individuals also emerge from childhood surgery with a different footprint than those in prior decades, further complicating the interpretation, and relevance of past RCTs. Therefore, thorough observational studies have been crucial to the development of ACHD guidelines, and with consensus statements inform much of the ACHD literature. As highlighted in this review, some recommendations mirror those in general cardiology, such as the management of acute ventricular arrhythmias, while drawing attention to the physiological differences in certain congenital diagnoses (such as lower resting blood pressure or hypoxia, possible meso-position or dextro-position of the heart) and the haemodynamic reserve and stability of some young patients despite ventricular tachycardia (VT). Similar to general guidelines, implantable cardioverter-defibrillators (ICDs) have …