Richard Brandon Stacey

Prediabetes and the association with unrecognized myocardial infarction in the multi-ethnic study of atherosclerosis

BACKGROUND With one-quarter of initial myocardial infarctions (MI) being unrecognized MI (UMI), recognition is critical to minimize further cardiovascular risk. Diabetes mellitus is an established risk factor for UMI. If impaired fasting glucose (IFG) also increased the risk for UMI, it would represent a significant public health challenge due to the rapid worldwide increase in IFG prevalence. We compared participants with IFG to those with normal fasting glucose (NFG) to determine if IFG was associated with UMIs. METHODS We performed cross-sectional analyses from the MESA, a population-based cohort study. There were 6,814 participants recruited during July 2000 to September 2002 from the general community at 6 field sites. After excluding those with diabetes mellitus or missing variables, 5,885 participants were included. At baseline, there were 4,955 participants with NFG and 930 participants with IFG. The main outcome was an UMI defined by the presence of pathological Q waves or minor Q waves with ST-T abnormalities on initial 12-lead electrocardiogram. Logistic regression was used to generate crude ORs and adjust for covariates. RESULTS There was a higher prevalence of UMI in those with IFG compared with those with NFG [3.5% (n = 72) vs 1.4% (n = 30)]. After adjustment for multiple risk factors, there was a higher odds of an UMI among those with IFG compared with those with NFG [OR: 1.60 (95% CI: 1.0-2.5); P = .048]. CONCLUSIONS Impaired fasting glucose is associated with unrecognized myocardial infarctions in a multi-ethnic population free of baseline cardiovascular disease.

Prolongation of QTc intervals and risk of death among patients with sickle cell disease

Unexplained sudden death is common among patients with sickle cell diseases (SCD). QTc prolongation is a risk factor for fatal arrhythmias among adults. This study sought to identify the predictors for QTc prolongation and determine whether QTc prolongation is associated with increased mortality in patients with SCD.

Echocardiography-Derived Tricuspid Regurgitant Jet Velocity Is an Important Marker for the Progression of Sickle-Cell Disease

Background: Although echocardiography-derived tricuspid regurgitant jet velocity (TRV) is associated with increased mortality in sickle-cell disease (SCD), it is unclear whether increased TRV is a marker of multiorgan disease due to systemic vasculopathy or related to increased pulmonary artery systolic pressure with episodes of multiple acute chest syndrome (ACS). Methods: Our study analyzed 148 consecutive patients with transthoracic echocardiography with TRV data, who came to our adult SCD Clinic at the Wake Forest Baptist Medical Center. For our analysis, we took TRV ≥2.5 m/s as elevated. Patients were followed on average for 9 years. Results: TRV ≥3 m/s was significantly associated with increased mortality (p < 0.001), thromboembolism (p < 0.001), hospitalization for ACS (p < 0.001), supraventricular arrhythmia (p = 0.028), right ventricular (RV) dilation, decreased hemoglobin and increased creatinine. Patients with a progressive increase in TRV during follow-up had increased mortality (36.7 vs. 8.6%, p = 0.007) and increased ACS (45 vs. 5.7%, p < 0.001). Death was independently associated with TRV ≥3 m/s (p = 0.023), ACS (p = 0.001) and increased RV basal diameter (p = 0.003). Conclusions: TRV is an important global marker for the severity and progression of SCD, and carries a significant prognostic implication.

Abnormal Stress‐Related Measures of Arterial Stiffness in Middle‐Aged and Elderly Men and Women With Impaired Fasting Glucose at Risk for a First Episode of Symptomatic Heart Failure

Background Abnormal resting arterial stiffness is present in middle‐aged and elderly persons with abnormalities of fasting glucose (diabetes or impaired fasting glucose) and is associated with exercise intolerance. We sought to determine whether these same persons exhibited stress‐related abnormalities of arterial stiffness. Methods and Results We analyzed dobutamine magnetic resonance stress imaging results from 373 consecutively recruited persons aged 55 to 85 years with normal fasting glucose, impaired fasting glucose, or diabetes who were at risk for but without symptomatic heart failure. Personnel blinded to participant identifiers measured arterial stiffness (brachial pulse pressure/left ventricular stroke volume indexed to body surface area, the aortic elastance index [brachial end‐systolic pressure/left ventricular stroke volume indexed to body surface area], and thoracic aortic distensibility) at 80% of the maximum predicted heart rate response for age. Participants averaged 69±8 years of age; 79% were white, 92% were hypertensive, and 66% were women. After accounting for hypertension, sex, coronary artery disease, smoking, medications, hypercholesterolemia, and visceral fat, we observed an effect of glycemic status for stress measures of arterial stiffness in those with diabetes and impaired fasting glucose relative to those with normal fasting glucose (P=0.002, P=0.02, and P=0.003, respectively). Conclusion Middle‐ and older‐aged individuals with diabetes or impaired fasting glucose have higher stress measures of arterial stiffness than those with normal fasting glucose. These data emphasize the need for future studies with larger sample sizes to determine whether stress‐related elevations in arterial stiffness are related to exercise intolerance and future episodes of heart failure experienced by those with abnormalities of fasting glucose. Clinical Trial Registration URL: http://clinicaltrials.gov/. Unique identifier: NCT00542503.

Cardiac magnetic resonance in cardiac angiosarcoma

While echocardiography is effective for initial identification of anatomic location, magnetic resonance imaging (MRI) is a more advantageous modality for delineating tumor expanse, spread, and blood supply preoperatively. Emerging patterns may even help generate a specific diagnosis prior to biopsy and histopathology.

Prediabetes: An Emerging Risk Factor for Coronary Artery Disease

Abstract Prediabetes affects almost 40% of the United States, a significant proportion of the population. While most readily recognize the risks imposed by diabetes mellitus, fewer clinicians and patients recognize the potential risks associated with being diagnosed with prediabetes. Diabetes causes both micro- and macrovascular complications. The prevention of these complications serves as a significant target of evidence-based guidelines. Data continue to emerge that many of these classic complications associated with diabetes mellitus actually initiate and potentially manifest during the prediabetic state. Even marginally elevated blood glucose levels increase systemic inflammation and with atherosclerosis being a type of arterial injury and its inflammatory response, it should come as no surprise that prediabetics have a greater atherosclerotic burden than their normal glycemic counterparts. Furthermore, many patients who initially present with a myocardial infarction are found to be prediabetic, and prediabetics experience more cardiovascular events after having a myocardial infarction. In diabetics, silent myocardial infarctions represent the intersection of the recognizing macro- and microvascular complications. Emerging data indicate that prediabetics also develop silent myocardial infarctions. The most efficacious means available to prevent the risks imposed by prediabetes and prevent the progression to overt diabetes mellitus remains exercise and dietary changes. With a substantial segment of the population being prediabetic, public health measures should continue to reinforce the critical nature of a heart healthy lifestyle featuring exercise and prudent dietary choices to prevent the cardiovascular morbidity and mortality associated with an abnormal blood glucose level.

Abnormal Fasting Glucose Increases Risk of Unrecognized Myocardial Infarctions in an Elderly Cohort: IFG AND UMI

To investigate glucose levels as a risk factor for unrecognized myocardial infarctions (UMIs).

Response: Cardiac magnetic resonance in cardiac angiosarcoma-Which contrast-enhancement pattern is typical?

We want to thank Drs. Tudos and Hutyra for their interest in our recent publication.1 We appreciate their experience and insight in imaging patients with cardiac angiosarcoma. They have raised several critical points in approaching patients with cardiac angiosarcoma. Of particular interest, the question arises whether certain patterns allow for the cardiovascular imaging specialists to positively identify cardiac angiosarcoma as opposed to other malignant pathologies. Specifically, they raise the point of whether the “sunray” appearance often cited represents a valid finding to differentiate cardiac angiosarcoma. While the “sunray” description is often mentioned in limited case presentations,2-4 Dr. Colin and colleagues shared the finding of rim enhancement described in a recent case series of 7 patients with cardiac angiosarcoma that allowed them to differentiate cardiac angiosarcoma from lymphoma.5 Unfortunately, much of what we know about the pathognomonic findings of cardiac angiosarcoma on magnetic resonance imaging rests on case reports and small series. Further complicating the issue, most cardiac tumors are initially imaged in settings where the knowledge and interpretation of cardiac tumors remain more limited. As more patients with cardiac tumors potentially enroll in cancer registries, this may provide us with the opportunity to better review the diagnostic imaging and identify imagingspecific features to diagnose, treat, and follow patients with this critical diagnosis. By combining data from single centers to form multiinstitutional registries, the strength of our knowledge and evidence grows significantly. CONFLICT OF INTEREST

CARDIAC-CYCLE RELATED CHANGES IN TRABECULATED LEFT VENTRICULAR VOLUME IN CARDIAC MAGNETIC RESONANCE IMAGING

Most measures of LV noncompaction cardiomyopathy (LVNC) are acquired from 2-D assessments. This study describes the changes in trabeculated volume during the cardiac cycle and its relationship to events related to LVNC. We retrospectively identified 122 cases of cardiac magnetic resonance with

TRANSCATHETER AORTIC VALVE REPLACEMENT CUSTOMIZATION BASED ON PARAVALVULAR AORTIC REGURGITATION LOCATION

Current limitations of transcatheter aortic valve replacement include paravalvular aortic regurgitation (PAR). We hypothesized that there are varying propensities for location of PAR in the Medtronic CoreValve and the Edwards Sapien Valve. The secondary goal was to longitudinally evaluate PAR