Andrew Krumerman

Validation of the Framingham Heart Study and CHARGE-AF Risk Scores for Atrial Fibrillation in Hispanics, African-Americans, and Non-Hispanic Whites

A risk score for atrial fibrillation (AF) has been developed by the Framingham Heart Study and Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE)-AF consortium. However, validation of these risk scores in an inner-city population is uncertain. Thus, a validation model was built using the Framingham Risk Score for AF and CHARGE-AF covariates. An in and outpatient electrocardiographic database was interrogated from 2000 to 2013 for the development of AF. Patients were included if their age was >45 and <95 years, had <10-year follow-up, if their initial electrocardiogram was without AF, had ≥ 2 electrocardiograms, and declared a race and/or ethnicity as non-Hispanic white, African-American, or Hispanic. For the Framingham Heart Study, 49,599 patients met inclusion criteria, of which 4,860 developed AF. Discrimination analysis using area under the curve (AUC) for original risk equations: non-Hispanic white AUC = 0.712 (95% confidence interval [CI] 0.694 to 0.731), African-American AUC = 0.733 (95% CI 0.716 to 0.751), and Hispanic AUC = 0.740 (95% CI 0.723 to 0.757). For the CHARGE-AF, 45,571 patients met inclusion criteria, of which 4,512 developed AF. Non-Hispanic white AUC = 0.673 (95% CI 0.652 to 0.694), African-American AUC = 0.706 (95% CI 0.685 to 0.727), and Hispanic AUC = 0.711 (95% CI 0.691 to 0.732). Calibration analysis showed qualitative similarities between cohorts. In conclusion, this is the first study to validate both the Framingham Heart Study and CHARGE-AF risk scores in both a Hispanic and African-American cohort. All models predicted AF well across all race and ethnic cohorts.

Socioeconomic status and the development of atrial fibrillation in Hispanics, African Americans and non-Hispanic whites

Atrial fibrillation (AF) is the most common arrhythmia and is associated with significant morbidity and mortality. Despite having a higher burden of traditional AF risk factors, African American and Hispanic minorities have a lower incidence of AF when compared to non‐Hispanic whites, referred to as the “racial paradox.”

Validation of PR interval length as a criterion for development of atrial fibrillation in non-Hispanic whites, African Americans and Hispanics

BACKGROUNDnPR interval prolongation on electrocardiogram (ECG) increases the risk of atrial fibrillation (AF). Non-Hispanic Whites are at higher risk of AF compared to African Americans and Hispanics. However, it remains unknown if prolongation of the PR interval for the development of AF varies by race/ethnicity. Therefore, we determined whether race affects the PR interval lengths ability to predict AF and if the commonly used criterion of 200 ms in AF prediction models can continue to be used for non-White cohorts.nnnMETHODSnThis is a retrospective epidemiological study of consecutive inpatient and outpatients. An ECG database was initially interrogated. Patients were included if their initial ECG demonstrated sinus rhythm and had two or more electrocardiograms and declared a race and/or ethnicity as non-Hispanic White, African American or Hispanic. Development of AF was stratified by race/ethnicity along varying PR intervals. Cox models controlled for age, gender, race/ethnicity, systolic blood pressure, BMI, QRS, QTc, heart rate, murmur, treatment for hypertension, heart failure and use of AV nodal blocking agents to assess PR intervals predictive ability for development of AF.nnnRESULTSn50,870 patients met inclusion criteria of which 5,199 developed AF over 3.72 mean years of follow-up. When the PR interval was separated by quantile, prolongation of the PR interval to predict AF first became significant in Hispanic and African Americans at the 92.5th quantile of 196-201 ms (HR: 1.42, 95% CI: 1.09-1.86, p=0.01; HR: 1.32, 95% CI: 1.07-1.64, p=0.01, respectively) then in non-Hispanic Whites at the 95th quantile at 203-212 ms (HR: 1.24, 95% CI: 1.24-1.53, p=0.04). For those with a PR interval above 200 ms, African Americans had a lower risk than non-Hispanic Whites to develop AF (HR: 0.80, 95% CI: 0.64-0.95, p=0.012), however, no significant difference was demonstrated in Hispanics.nnnCONCLUSIONSnThis is the first study to validate a PR interval value of 200 ms as a criterion in African Americans and Hispanics for the development of AF. However, a value of 200 ms may be less sensitive as a predictive measure for the development of AF in African Americans compared to non-Hispanic Whites.

Relation of Body Mass Index to Development of Atrial Fibrillation in Hispanics, Blacks, and Non-Hispanic Whites

No previous studies have examined the interaction between body mass index (BMI) and race/ethnicity with the risk of atrial fibrillation (AF). We retrospectively followed 48,323 persons free of AF (43% Hispanic, 37% black, and 20% white; median age 60 years) for subsequent incident AF (ascertained from electrocardiograms). BMI categories included very severely underweight (BMI <15u2009kg/m2), severely underweight (BMI 15.1 to 15.9u2009kg/m2), underweight (BMI 16 to 18.4u2009kg/m2), normal (BMI 18.5 to 24.9u2009kg/m2), overweight (BMI 25.0 to 29.9u2009kg/m2), moderately obese (BMI 30 to 34.9u2009kg/m2), severely obese (BMI 35 to 39.9u2009kg/m2), and very severely obese (BMI >40u2009kg/m2). Cox regression analysis controlled for baseline covariates: heart failure, gender, age, treatment for hypertension, diabetes, PR length, systolic blood pressure, left ventricular hypertrophy, socioeconomic status, use of β blockers, calcium channel blockers, and digoxin. Over a follow-up of 13 years, 4,744 AF cases occurred. BMI in units of 10 was associated with the development of AF (adjusted hazard ratio 1.088, 95% confidence interval 1.048 to 1.130, p <0.01). When stratified by race/ethnicity, non-Hispanic whites compared with blacks and Hispanics had a higher risk of developing AF, noted in those whom BMI classes were overweight to severely obese. In conclusion, our study demonstrates that there exists a relation between obesity and race/ethnicity for the development of AF. Non-Hispanic whites had a higher risk of developing AF compared with blacks and Hispanics.

LEFT ATRIAL APPENDAGE MORPHOLOGY AND STROKE RISK IN PATIENTS WITH ATRIAL FIBRILLATION: A META-ANALYSIS

The left atrial appendage (LAA) has been classified according to its morphology into 4 different types (Chicken Wing (CW), Cauliflower, Windsock and Cactus). LAA morphology has been found to independently influence the thromboembolic (TE) risk in patients with atrial fibrillation (AF). TE risk

The Prognostic Value of Early Repolarization with ST‐Segment Elevation by Age and Gender in the Hispanic Population

Early repolarization (ER), once thought to be a benign finding on electrocardiograph (ECG), has recently been associated with an increased risk of sudden cardiac death. As there are limited data in the Hispanic population, we investigated possible associations between automated ECG ER readings and overall mortality, using the classic definition involving J‐point elevation with ST segment elevation.

Relative contribution of modifiable risk factors for incident atrial fibrillation in Hispanics, African Americans and non-Hispanic Whites

BACKGROUNDnContribution of modifiable risk factors for the risk of new onset atrial fibrillation (AF) in minority populations is poorly understood. Our objective was to compare the population attributable risk (PAR) of various risk factors for incident AF between Hispanic, African American and non-Hispanic Whites.nnnMETHODSnAn ECG/EMR database was interrogated for individuals free of AF for development of subsequent AF from 2000 to 2013. Cox regression analysis controlled for ageu202f>u202f65, male gender, body mass indexu202f>u202f40u202fkg/m2, systolic blood pressureu202f>u202f140u202fmmu202fHg, diabetes mellitus, heart failure, socioeconomic status less than the first percentile in New York State, and race/ethnicity. PAR was calculated as (prevalence of X)u202f∗u202f(HRu202f-u202f1)/HR, where HR is the hazard ratio, and X is the risk factor.nnnRESULTSn47,722 persons free of AF (43% Hispanic, 37% Black and 20% White) were followed for subsequent incident AF. Hypertension in African Americans and Hispanics had a 7.93% and 7.66% greater PAR compared with non-Hispanics Whites. Similar findings existed for the presence of heart failure, with a higher PAR in non-Whites compared to Whites.nnnCONCLUSIONnIn conclusion, modifiable risk factors play an important role in the risk of incident AF. Higher PAR estimates in African Americans and Hispanics were observed for elevated systolic blood pressure and heart failure. Identification of these modifiable risk factors for atrial fibrillation in non-White minorities may assist in targeting better prevention therapies and planning from a public health perspective. No funding sources were used for this study.

DIABETES MELLITUS AND THE DEVELOPMENT OF ATRIAL FIBRILLATION IN HISPANICS, BLACKS AND WHITES

Background: No previous studies have examined the interaction between diabetes mellitus (DM) across a large Hispanic, Black and White cohort with the development of atrial fibrillation (AF).nnMethods: We retrospectively followed 32,245 persons free of AF (46% Hispanic, 39% Black and 15% White, mean

Acute Orthotopic Heart Transplantation Rejection With ST-Segment Elevation in Leads I and aVL

Acute allograft rejection is a prominent cause of graft failure in heart transplant recipients. Graft infiltration with immune-mediated cells is associated with changes in electric conduction. ECG patterns in heart transplant rejection generally include changes in the electric activity of the atria. ST-segment elevation is an uncommon presentation in acute rejection. We describe a case of mixed cellular and humoral rejection in a 74-year-old man 5 years after orthotopic heart transplantation presenting with lateral ST-segment elevations on ECG and normal coronary arteries on coronary angiography. Endomyocardial biopsy revealed International Society for Heart and Lung Transplantation grade 3R severe acute cellular rejection with associated pAMR1 (I+) antibody–mediated rejection.nnA 74-year-old man with chronic heart failure caused by an ischemic cardiomyopathy who underwent heart transplantation 5 years previously presented with left-sided chest pain of 4 days duration. Associated symptoms included dyspnea on exertion, fatigue, orthopnea, paroxysmal nocturnal dyspnea, and nausea. The past medical history was notable for an episode of acute cellular rejection 4 years before admission. The patient’s medications included aspirin, rosuvastatin, clonidine, and a 2-drug immunosuppresion regimen consisting of …