Chike C. Nwabuo

Factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension.

Background Missed appointments are associated with an increased risk of hospitalization and mortality. Despite its widespread prevalence, little data exists regarding factors related to appointment non-adherence among hypertensive African-Americans. Objective To investigate factors associated with appointment non-adherence among African-Americans with severe, poorly controlled hypertension. Design and Participants A cross-sectional survey of 185 African-Americans admitted to an urban medical center in Maryland, with severe, poorly controlled hypertension from 1999–2004. Categorical and continuous variables were compared using chi-square and t-tests. Adjusted multivariable logistic regression was used to assess correlates of appointment non-adherence. Main Outcome Measures Appointment non-adherence was the primary outcome and was defined as patient-report of missing greater than 3 appointments out of 10 during their lifetime. Results Twenty percent of participants (n = 37) reported missing more than 30% of their appointments. Patient characteristics independently associated with a higher odds of appointment non-adherence included not finishing high school (Odds ratio [OR] = 3.23 95% confidence interval [CI] (1.33–7.69), hypertension knowledge ([OR] = 1.20 95% CI: 1.01–1.42), lack of insurance ([OR] = 6.02 95% CI: 1.83–19.88), insurance with no medication coverage ([OR] = 5.08 95% CI: 1.05–24.63), cost of discharge medications ([OR] = 1.20 95% CI: 1.01–1.42), belief that anti-hypertensive medications do not work ([OR] = 3.67 95% CI: 1.16–11.7), experience of side effects ([OR] = 3.63 95% CI: 1.24–10.62), medication non-adherence ([OR] = 11.31 95% CI: 3.87–33.10). Substance abuse was not associated with appointment non-adherence ([OR] = 1.05 95% CI: 0.43–2.57). Conclusions Appointment non-adherence among African-Americans with poorly controlled hypertension was associated with many markers of inadequate access to healthcare, knowledge, attitudes and beliefs.

Association of Aortic Root Dilation from Early Adulthood to Middle Age with Cardiac Structure and Function: The CARDIA Study

Background: The human aorta dilates with advancing age. However, the association between progressive aortic dilation with aging and cardiac remodeling has not been established in studies of community‐dwelling adults. The aim of this study was to test the hypothesis that there would be a relationship between aortic size increase over the early adult life span with left ventricular (LV) structural remodeling and subclinical LV dysfunction in middle age, even in the absence of overt cardiovascular and valvular disease. Methods: Included were Coronary Artery Risk Development in Young Adults study participants (N = 2,933) aged 23 to 35 years with available transthoracic echocardiographic measurements during 20 years of follow‐up. Multivariate linear regression models assessed sex‐specific associations between 20‐year change in aortic root diameter with LV structure and function. Results: Larger aortic root diameter at 20‐year follow‐up was associated with greater LV mass (2.77 vs 2.18 g/mm in men and women, respectively, P < .001). In longitudinal analyses, increase in aortic root diameter over 20‐year follow‐up was associated with a greater 20‐year increase in LV mass and ratio of LV mass to LV end‐diastolic volume ratio in both sexes. In women but not in men, increased aortic root diameter over 20 years was associated with increased left atrial dimension, impaired E/E′, and impaired early diastolic longitudinal and circumferential strain rates assessed by speckle‐tracking echocardiography. Conclusions: Progressive increase in aortic root diameter from early adulthood to middle age was associated with increased LV mass and LV concentric remodeling in both sexes and impaired diastolic function predominantly in women. HighlightsAortic root dilation over the early adult life‐cycle is associated with impaired diastolic function predominantly in women.Aortic root dilation from early adulthood to middle age is associated with increased left ventricular mass and left ventricular concentric remodeling in community‐dwelling individuals.Our study findings support the hypothesis that aortic root dilation is associated with adverse cardiac remodeling and underscore the potential importance of sex‐specific ventricular‐arterial interactions in the pathogenesis of heart failure. Abbreviations: AoD = Aortic root diameter; CARDIA = Coronary Artery Risk Development in Young Adults; LV = Left ventricular; LVM = Left ventricular mass; STE = Speckle‐tracking echocardiography.

Evaluation of Right Ventricular Systolic Function in Chagas Disease Using Cardiac Magnetic Resonance ImagingCLINICAL PERSPECTIVE

Background— Right ventricular (RV) impairment is postulated to be responsible for prominent systemic congestion in Chagas disease. However, occurrence of primary RV dysfunction in Chagas disease remains controversial. We aimed to study RV systolic function in patients with Chagas disease using cardiac magnetic resonance. Methods and Results— This cross-sectional study included 158 individuals with chronic Chagas disease who underwent cardiac magnetic resonance. RV systolic dysfunction was defined as reduced RV ejection fraction based on predefined cutoffs accounting for age and sex. Multivariable logistic regression was used to verify the relationship of RV systolic dysfunction with age, sex, functional class, use of medications for heart failure, atrial fibrillation, and left ventricular systolic dysfunction. Mean age was 54±13 years, 51.2% men. RV systolic dysfunction was identified in 58 (37%) individuals. Although usually associated with reduced left ventricular ejection fraction, isolated RV systolic dysfunction was found in 7 (4.4%) patients, 2 of them in early stages of Chagas disease. Presence of RV dysfunction was not significantly different in patients with indeterminate/digestive form of Chagas disease (35.7%) compared with those with Chagas cardiomyopathy (36.8%) (P=1.000). Conclusions— In chronic Chagas disease, RV systolic dysfunction is more commonly associated with left ventricular systolic dysfunction, although isolated and early RV dysfunction can also be identified.

Relation of Sex Hormone Levels With Prevalent and 10-Year Change in Aortic Distensibility Assessed by MRI: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND Women experience a steeper decline in aortic elasticity related to aging compared to men. We examined whether sex hormone levels were associated with ascending aortic distensibility (AAD) in the Multi-Ethnic Study of Atherosclerosis. METHODS We studied 1,345 postmenopausal women and 1,532 men aged 45-84 years, who had serum sex hormone levels, AAD measured by phase-contrast cardiac magnetic resonance imaging, and ejection fraction>50% at baseline. Among these participants, 457 women and 548 men returned for follow-up magnetic resonance imaging 10-years later. Stratified by sex, and using mixed effects linear regression methods, we examined associations of sex hormones (as tertiles) with baseline and annual change in log-transformed AAD (mm Hg-110-3), adjusting for demographics, body size, lifestyle factors, mean arterial pressure, heart rate, hypertensive medication use (and in women, for hormone therapy use and years since menopause). RESULTS The mean (SD) age was 65 (9) for women and 62 (10) years for men. AAD was lower in women than men (P < 0.001). In adjusted cross-sectional analysis, the highest tertile of free testosterone (compared to lowest) in women was significantly associated with lower AAD [-0.10 (-0.19, -0.01)] and the highest tertile of estradiol in men was associated with greater AAD [0.12 (0.04, 0.20)]. There were no associations of sex hormones with change in AAD over 10 years, albeit in a smaller sample size. CONCLUSIONS Lower free testosterone in women and higher estradiol in men were associated with greater aortic distensibility at baseline, but not longitudinally. Sex hormone levels may account for differences in AAD between women and men.

Association of Gestational Diabetes Mellitus With Left Ventricular Structure and Function: The CARDIA Study

OBJECTIVE Gestational diabetes mellitus (GDM) predicts incident cardiovascular disease (CVD). However, mechanisms linking GDM to CVD beyond intervening incident diabetes are not well understood. We examined the relation of GDM with echocardiographic parameters of left ventricular (LV) structure and function, which are important predictors of future CVD risk. RESEARCH DESIGN AND METHODS We studied 609 women (43% black) from the Coronary Artery Risk Development in Young Adults (CARDIA) study who delivered one or more births during follow-up and had echocardiograms in 1990–1991 (mean age 28.8 years) and 2010–2011. RESULTS During the 20-year follow-up, 965 births were reported, with GDM developing in 64 women (10.5%). In linear regression models adjusted for sociodemographic factors, BMI, physical activity, parity, smoking, use of oral contraceptives, alcohol intake, family history of coronary heart disease, systolic blood pressure, and lipid levels, women with GDM had impaired longitudinal peak strain (−15.0 vs. −15.7%, P = 0.025), circumferential peak strain (−14.8 vs. −15.6%, P = 0.028), lateral e′ wave velocity (11.0 vs. 11.8 cm/s, P = 0.012), and septal e′ wave velocity (8.6 vs. 9.3 cm/s, P = 0.015) in 2010–2011 and a greater 20-year increase in LV mass indexed to body surface area (14.3 vs. 6.0 g/m2, P = 0.006) compared with women with non-GDM pregnancies. Further adjustment for incident type 2 diabetes after pregnancy did not attenuate these associations. CONCLUSIONS Pregnancy complicated by GDM is independently associated with increased LV mass and impaired LV relaxation and systolic function. Implementation of postpartum cardiovascular health interventions in women with a history of GDM may offer an additional opportunity to reduce future CVD risk.

Sex Hormone Levels and Change in Left Ventricular Structure Among Men and Post-Menopausal Women: The Multi-Ethnic Study of Atherosclerosis (MESA)

OBJECTIVE Sex hormone (SH) levels may contribute to sex differences in the risk of heart failure with preserved ejection fraction (HFpEF). We examined the associations of SH levels with left ventricular mass (LVM) and mass (M):volume (V) ratio, which are risk markers for HFpEF. STUDY DESIGN We studied 1941 post-menopausal women and 2221 men, aged 45-84 years, participating in the Multi-Ethnic Study of Atherosclerosis (MESA). Serum SH levels, cardiac magnetic resonance imaging (MRI) and ejection fraction (EF) ≥50% had been recorded at baseline (2000-2002). Of these participants, 2810 underwent repeat MRI at Exam 5 (2010-2012). Stratified by sex, linear mixed-effect models were used to test associations between SH and sex hormone binding globulin (SHBG) level [per 1 SD greater log-transformed (SH)] with baseline and change in LV structure. Models were adjusted for age, race/ethnicity, center, height, weight, education, physical activity and smoking, and, in women, for hormone therapy and years since menopause. MAIN OUTCOME MEASURES LVM and M:V ratio. RESULTS After a median of 9.1 years, higher free testosterone levels were independently associated with a modest increase in LVM (g/yr) in women [0.05 (95% CI 0.01, 0.10)] and men [0.16 (0.03, 0.28)], while higher SHBG levels were associated with less LVM change (g/yr) in women [-0.07 (-0.13, -0.01)] and men [-0.15 (-0.27, -0.02)]. In men, higher dehydroepiandrosterone and estradiol levels were associated with increased LVM. Among women, free testosterone levels were positively and SHBG levels inversely associated with change in M:V ratio. CONCLUSION A more androgenic profile (higher free testosterone and lower SHBG levels) is associated with a greater increase in LVM in men and women and greater increase in M:V ratio in women over the course of 9 years.

Echocardiographic Pulmonary Artery Systolic Pressure in the Coronary Artery Risk Development in Young Adults (CARDIA) Study: Associations With Race and Metabolic Dysregulation

Background The determinants of pulmonary artery systolic pressure (PASP) are not fully understood. It is unknown whether racial differences in PASP exist or if other population characteristics are associated with pulmonary pressure in humans. We examined echocardiographically estimated PASP in the Coronary Artery Risk Development in Young Adults (CARDIA) study, a middle‐aged, biracial community‐based cohort. Methods and Results At the CARDIA year‐25 examination, 3469 participants underwent echocardiography, including measurement of tricuspid regurgitant jet velocity to estimate PASP. Clinical features, laboratory values, pulmonary function tests, and measurement of adipose depot volume were analyzed for association with PASP. PASP was estimated in 1311 individuals (61% female, 51% white). Older age, higher blood pressure, and higher body mass index were associated with higher PASP. Black race was associated with higher PASP after adjustment for demographics and left and right ventricular function (β 0.94, 95% CI 0.24‐1.64; P=0.009), but this association was no longer significant after further adjustment for lung volume (β 0.42, 95% CI −0.68 to 0.96; P=0.74). Insulin resistance, inflammation (C‐reactive protein and interleukin‐6), and visceral adipose volume were independently associated with higher PASP after adjustment for relevant covariates. PASP rose with worsening diastolic function (ratio of early transmitral Doppler velocity to average mitral annular tissue Doppler velocity [E/e′] and left atrial volume index). Conclusions In a large biracial cohort of middle‐aged adults, we identified associations among black race, insulin resistance, and diastolic dysfunction with higher echocardiographically estimated PASP. Further studies are needed to examine racial differences in PASP and whether insulin resistance directly contributes to pulmonary vascular disease in humans.

Management of Cocaine-Induced Myocardial Infarction: 4-Year Experience at an Urban Medical Center.

Objectives In 2008, the American Heart Association and the American College of Cardiology released guidelines for the management of cocaine-induced myocardial infarction (CIMI). We hypothesized that CIMI patients are likely to receive less invasive and more conservative management than patients with MI without history of cocaine use. Methods We conducted a retrospective analysis on patients younger than 65 years presenting with acute MI between April 1, 2008 and December 31, 2012. Patients were classified as cocaine-negative MI or CIMI based on either urine toxicology results or self-reported cocaine use. Categorical and continuous variables were compared using &khgr;2 or t test as appropriate. The primary outcome was cardiac catheterization or stress testing. The secondary outcome was a 30-day readmission rate for major adverse cardiovascular events. Multiple logistic regression models calculated odds ratios (ORs) for the primary outcomes adjusting for patient demographics and comorbidities. Results Of 378 MI patients, 4.2 % had CIMI. CIMI patients were younger (50 vs 54 years; P < 0.01) predominantly African American (56% vs 16%, P < 0.01), and mostly active smokers (88% vs 58%, P = 0.02). They were more likely to receive stress testing (adjusted OR 3.61, 95% confidence interval 1.04–12.53) and less likely to undergo cardiac catheterization (adjusted OR 0.12, 95% confidence interval 0.03–0.45). The 30-day readmission rate for major adverse cardiovascular events was higher in CIMI compared with cocaine-negative MI patients (38% vs 13%; P = 0.03). Conclusions The use of cocaine in patients presenting with acute MI appears to impact management decisions of providers. Patient-centered postdischarge arrangements need better coordination for this patient group to optimize their follow-up care.

Right Ventricular Systolic Dysfunction in Chagas Disease Defined by Speckle-Tracking Echocardiography: A Comparative Study with Cardiac Magnetic Resonance Imaging

Background: Chagas disease leads to biventricular heart failure, usually with prominent systemic congestion. Although echocardiography is widely used in clinical routine, the utility of echocardiographic parameters to detect right ventricular (RV) systolic dysfunction in patients with Chagas disease is unknown. We sought to study the diagnostic value of echocardiography, including speckle‐tracking parameters, to distinguish individuals with RV systolic dysfunction from those with normal RV systolic function in Chagas disease using cardiac magnetic resonance (CMR) as the reference method. Methods: In this cross‐sectional study, 63 individuals with Chagas disease underwent echocardiography and CMR evaluations. Conventional echocardiographic parameters for RV functional evaluation were tricuspid annular plane systolic excursion, RV systolic excursion velocity, fractional area change, and RV index of myocardial performance. Strain and strain rate were obtained by two‐dimensional speckle‐tracking echocardiography and defined as “RV free wall,” when based only in segments from RV free wall, or “RV free wall and septum,” when segments from both free RV wall and interventricular septum were included. RV systolic dysfunction was defined as RV ejection fraction (RVEF) < 50% by CMR. Results: Mean age was 56 ± 14 years, and 58.7% of the patients were men. RV systolic dysfunction was detected by CMR in 18 (28.6%) individuals. RV free wall strain showed the highest correlation with RVEF by CMR (r = −0.62, P < .001), followed by fractional area change (r = 0.56, P < .001), RV free wall and septum strain (r = −0.54, P < .001), RV free wall and septum strain rate (r = −0.47, P < .001), RV free wall strain rate (r = −0.45, P < .001), and RV systolic excursion velocity (r = 0.30, P = .016). The RV index of myocardial performance and tricuspid annular plane systolic excursion showed a small and not significant correlation with RVEF (r = −0.20, P = .320; r = 0.14; P = .289, respectively). Using predefined cutoffs for RV systolic dysfunction, RV free wall strain (>−22.5% for men and >−23.3% for women) exhibited the highest area under the receiver operating characteristic curve (area under the curve = 0.829) to differentiate the presence from the absence of RV systolic dysfunction in Chagas disease, with a sensitivity and specificity of 67% and 83%, respectively. Conclusions: RV free wall strain is an appropriate and superior echocardiographic variable for evaluating RV systolic function in Chagas disease, and it should be the method of choice for this purpose. HighlightsSpeckle‐tracking echocardiography is a valuable technique to assess RV function.Right ventricular (RV) free wall strain is the method of choice for RV evaluation in Chagas disease.The sensitivity of tricuspid annular plane systolic excursion, RV systolic excursion velocity, fractional area change, and RV index of myocardial performance to detect RV dysfunction is much lower.

Cumulative blood pressure from early adulthood to middle age is associated with left atrial remodelling and subclinical dysfunction assessed by three-dimensional echocardiography: a prospective post hoc analysis from the coronary artery risk development in young adults study

Abstract Aims To evaluate the association of cumulative blood pressure (BP) from young adulthood to middle age with left atrial (LA) structure/function as assessed by three-dimensional echocardiography (3DE) in a large longitudinal bi-racial population study. Methods and results We conducted a prospective post hoc analysis of individuals enrolled at the Coronary Artery Risk Development in Young Adults, which is a multi-centre bi-racial cohort with 30 years of follow-up. Cumulative systolic and diastolic BP levels were defined by summing the product of average millimetres of mercury and the years between each two consecutive clinic visits over 30 years of follow-up. Multivariable linear regression analyses were used to assess the relationship between cumulative systolic and diastolic BP with 3DE LA structure and function, adjusting for demographics and traditional cardiovascular risk factors. A total of 1033 participants were included, mean age was 55.4 ± 3.5 years, 55.2% women, 43.9% blacks. Cumulative systolic BP had stronger correlations than cumulative diastolic BP. Higher cumulative systolic BP was independently associated with higher 3D LA volumes: maximum (β = 1.74, P = 0.004), pre-atrial contraction (β = 1.87, P < 0.001), minimum (β = 0.76, P = 0.04), total emptying (β = 0.98, P = 0.006), active emptying (β = 1.12, P < 0.001), and lower magnitude 3D LA early diastolic strain rate (β = 0.05, P = 0.02). Higher cumulative diastolic BP was independently associated with higher 3D LA active emptying volume (β = 0.66, P = 0.002), lower magnitude 3D LA early diastolic strain rate (β = 0.05, P = 0.004), and higher magnitude 3D LA late diastolic strain rate (β = −0.04, P = 0.05). Conclusion Higher cumulative BP from early adulthood throughout middle age was associated with adverse LA remodelling evaluated by 3D echocardiography.