Faraj Kargoli

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.

Quality of care among patients undergoing lower extremity revascularization

Background: Compliance with guidelines for treating patients with peripheral artery disease (PAD) lags compliance for treating patients with coronary artery disease. We assessed the gap between guidelines and practice for patients with PAD who underwent lower extremity revascularization (LER) at our institution from 2007 to 2010. Methods: Quality of care (QoC) was calculated by measuring provider performance on four indicators (antiplatelet therapy, dyslipidemia management, control of hypertension, and diabetes) derived from the ACCF/AHA PAD guidelines. The QoC score was calculated at the time of admission and at time of discharge for each patient, and reflects the proportion of indicated treatments received. Results: Patients (n = 734, mean age 70±11, female 51%) were followed for a mean of 2.0±1.4 years (range 0–5.7) following LER. The indication for LER was claudication (24.8%), rest pain (16.7%), and tissue loss (58.4%). The percentage of patients with a perfect QoC score increased significantly during hospital admission (11% to 21%, p < 0.001). Significant multivariate predictors of perfect QoC score included race/ethnicity, Charlson score, severity of LE ischemia, and observation period (admission, discharge). Multivariate analysis demonstrated that age>75 years, heart failure, chronic kidney disease, rest pain, and tissue loss—but not compliance with four guideline-based therapies—were associated with decreased freedom from the composite endpoint of major amputation, repeat revascularization, and death. Conclusions: Although adherence to guidelines improved over time, we found a significant gap between guidelines and practice for this cohort of patients at increased risk for adverse cardiovascular events.

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.

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

PREVALENCE AND PROGNOSTIC SIGNIFICANCE OF CARDIAC TROPONIN-T ELEVATION IN PATIENTS ADMITTED WITH HYPERTENSIVE CRISES

Background: Hypertension is one of the most common chronic conditions in the world. Hypertensive crises (HC) are frequently associated with the release of cardiac troponin T (cTnT). However, limited data is available on the clinical significance of cTnT in patients with HC. We sought to study the