Journal of the American Heart Association最新文献

Background: Studies have shown an association of chronic kidney disease with heart failure (HF); however, this association has not been adequately examined in postmenopausal women, who are at heightened risk of both chronic kidney disease and HF. Additionally, association with HF subtypes is not well characterized.

Methods and results: Incident HF was defined as first hospitalization for acute decompensated HF, obtained by self-reported outcomes followed by physician adjudication through review of hospital records. Chronic kidney disease was defined using estimated glomerular filtration rate (eGFR). Restricted cubic splines tested the association of eGFR with incident overall HF, and HF with reduced ejection fraction (HFrEF) and preserved EF (HFpEF). Cox proportional hazards regression models evaluated the multivariable-adjusted association of eGFR categories with incident HF and its subtypes. The primary analysis included 23 309 women with 11 814 eGFR ≥90, 10 191 eGFR between 60 and 89, 1048 eGFR between 45 and 59 and 256 eGFR <45 mL/min per 1.73 m². For overall HF, HFrEF and HFpEF, there was a stepwise increase in risk for incident HF with declining eGFR category. Associations were stronger for HFpEF (hazard ratio [HR], 2.80 [95% CI, 2.36-3.32]) than for HFrEF (HR, 2.18 [95% CI, 1.66-2.87]) for eGFR <45 as compared with eGFR ≥90. Heterogeneity of the HF subdistributions (HFpEF versus HFrEF) was significant (P=0.017).

Conclusions: Kidney dysfunction is associated with incident HF in postmenopausal women. Although lower eGFR is associated with both incident HFrEF and HFpEF, the association is stronger with HFpEF.

Registration: URL: https://clinicaltrials.gov; Unique Identifier: NCT00000611.

Perinatal psychological health conditions (eg, perinatal depression, anxiety) are some of the leading causes of maternal mortality in the United States and are associated with adverse pregnancy outcomes, long-term cardiovascular outcomes, and intergenerational effects on offspring neurodevelopment. These risks underscore the importance of addressing maternal psychological health as a key determinant of perinatal cardiovascular health. Thus, it is vital to recognize the spectrum of perinatal psychological health and to provide guidance for both patients and clinicians on screening and management options across the perinatal period. In this scientific statement from the American Heart Association, we redefine maternal cardiovascular health to include psychological health, provide robust evidence on the association of psychological health with cardiovascular outcomes, highlight the social and environmental underpinnings, and finally, offer guidance about how to integrate psychological health into maternal cardiovascular health with a specific focus on the perinatal period (ie, pregnancy through 1 year postpartum). We also describe opportunities for creating care delivery models that recurrently address perinatal psychological health in cardio-obstetric care, using behavioral and pharmacological interventions, with an emphasis on better integration of psychological health care, longer postpartum follow-up, and opportunities for evaluating the comparative effectiveness of these models with stakeholder partners.

Background: Although intravenous thrombolysis (IVT) is safe and effective in populations with general stroke, its impact on cervical artery dissection-related acute ischemic stroke (CeAD-AIS) remains unclear. This retrospective study used the National Inpatient Sample to compare outcomes in patients with CeAD-AIS treated with and without IVT.

Methods: We included adult patients with concurrent CeAD and AIS diagnoses (International Classification of Diseases, Tenth Revision [ICD-10], codes) hospitalized from 2016 to 2019. The primary outcome was home discharge; safety outcomes included inpatient death and intracerebral hemorrhage. We performed survey-weighted multivariable logistic regressions comparing IVT versus no IVT, followed by interaction analyses to examine effect modifications based on age, medical history, stroke severity, carotid artery involvement, and endovascular treatment.

Results: Between 2016 and 2019, 1360 (12.1%) of 11 285 patients with CeAD-AIS received IVT. IVT-treated patients had higher median National Institutes of Health Stroke Scale scores (median [interquartile range], 8 [4-17] versus 3 [1-11]; P<0.001). Adjusted analyses showed IVT was associated with higher odds of home discharge (adjusted odds ratio [OR], 1.40 [95% CI, 1.01-1.92]; P=0.042), but not with inpatient death (adjusted OR, 1.29 [95% CI, 0.76-2.20]; P=0.347) or intracerebral hemorrhage (adjusted OR, 0.69 [95% CI, 0.32-1.48]; P=0.341). Stroke severity (P for interaction=0.001) and carotid artery involvement (P for interaction=0.021) significantly modified IVT's effect on home discharge, with IVT being associated with an increased likelihood of home discharge in patients with moderate to severe strokes (National Institutes of Health Stroke Scale score >4) and carotid artery involvement.

Conclusions: IVT improves the likelihood of home discharge in patients with CeAD-AIS without increasing the risk of inpatient death or intracerebral hemorrhage.

Background: We investigate whether the National Institutes of Health Stroke Scale (NIHSS) at 24 hours could serve as a primary outcome in acute ischemic stroke trials, and whether combining 90-day modified Rankin Scale (mRS) and 24-hour NIHSS in a hierarchical outcome could enhance detection of treatment effect, using endovascular treatment (EVT) as an exemplary study intervention.

Methods: This was a post hoc analysis of pooled data from 7 randomized EVT trials. Twenty-four-hour NIHSS as a surrogate outcome for 90-day mRS was assessed in a causal mediation model. A 7-point ordinal NIHSS score was generated by grouping 24-hour NIHSS, including death as a separate category ("ordinal" NIHSS). EVT effect sizes and sample sizes required for detecting EVT benefit with 80% power were compared when using granular 24-hour NIHSS, ordinal 24-hour NIHSS, 90-day mRS, and a hierarchical outcome (win ratio) that combines 90-day mRS and 24-hour NIHSS.

Results: A total of 1720 patients were included. Twenty-four-hour NIHSS mediated the association between EVT and 90-day mRS and met criteria for a useful surrogate outcome. Effect sizes were highest and sample sizes required to detect EVT benefit smallest for the win ratio approach (228), followed by 90-day mRS (240) and ordinal 24-hour NIHSS (242). In patients with baseline NIHSS <10 and ≥25, ordinal 24-hour NIHSS resulted in the highest effect size.

Conclusions: Twenty-four-hour NIHSS is a useful surrogate outcome for 90-day mRS in patients with acute ischemic stroke undergoing EVT, with a similar EVT effect size compared with 90-day mRS. It could potentially enhance detection of EVT benefit in patients with very low or high baseline NIHSS. An ordered hierarchical outcome could improve detection of EVT treatment effect.

The American Heart Association's Get With The Guidelines-Quality Improvement registry is a vital resource for real-world cardiovascular and stroke data and research, containing >14 million records from >2800 participating hospitals. To facilitate and streamline research, we aim to generate a synthetic data set that increases access to real-world data and facilitates data exploration of the Get With The Guidelines-Stroke registry. We first randomly sampled 1000 records from the entire registry data set from 2005 to 2021 containing 7.8 million records. To preserve privacy and break the links from the original data, we shifted all data time variables and replaced all patient identifiers. To evaluate the generated synthetic data, we compared the distributions of patient demographics (eg, age, race, sex) and other key stroke-related measures. The generated synthetic data exhibited similar distributions in age, race, sex, and time-sensitive metrics such as door-to-needle time and time to intravenous thrombolytic therapy, demonstrating that this open access data set can provide all researchers the opportunity to explore real-world cardiovascular and stroke data.

Background: Multimorbidity is common among patients with atrial fibrillation (AF) and is associated with worse outcomes. We aimed to investigate the association between multimorbidity, AF progression and AF symptom severity in patients with paroxysmal AF.

Methods and results: The RACE V (Reappraisal of AF: Interaction Between Hypercoagulability, Electrical Remodeling, and Vascular Destabilization in the Progression of AF) study included patients with paroxysmal AF and continuous rhythm monitoring. Multimorbidity was defined as ≥2 comorbidities (heart failure, hypertension, diabetes, coronary heart disease, kidney dysfunction, moderate or severe mitral valve regurgitation, or obesity). AF symptom severity was assessed via the University of Toronto AF Severity Scale questionnaire. The associations between multimorbidity, AF progression, and AF symptom severity were determined using logistic regression analyses. Median age was 65 (58-71) years and 179 of 417 patients (43%) were women, with a median of 1 (1-2) comorbidities. Median follow-up was 2.2 (1.6-2.8) years. Multimorbidity was associated with AF progression (odds ratio [OR], 2.02 [95% CI, 1.10-3.72], P=0.024) and increased AF symptom severity (OR, 2.67 [95% CI, 1.79-3.99], P<0.001). There was a positive dose-response relation between the number of comorbidities and AF progression (OR, 1.40 [95% CI, 1.09-1.79], P=0.008), as well as AF symptom severity (OR, 1.64 [95% CI, 1.35-1.99], P<0.001). These results remained significant after adjusting for age.

Conclusions: In patients with paroxysmal AF, multimorbidity was associated with AF progression and AF symptom severity. The risk of AF progression and AF symptom severity increased with every additional comorbidity.

Registration: URL: clinicaltrials.gov. Unique Identifier: NCT02726698.

Background: Low gestational vitamin D levels may increase offspring risk of cardiovascular disease from an early age. Studies investigating the impact on offspring macrovascular function have been inconsistent. Few included pulse wave velocity as an arterial stiffness indicator, and none included measures of microvascularization as an early marker of cardiovascular health. This study explored the association between gestational vitamin D levels and macro- and microvascular health across early adolescence.

Methods and results: We analyzed data from 430 mother-child pairs from a Spanish birth cohort. 25-hydroxyvitamin D₃ (vitamin D₃) levels were measured in serum at 13 weeks of pregnancy. At 11 and 15 years we assessed macrovascular parameters, including systolic and diastolic blood pressure (mm Hg) and pulse wave velocity (m/s), and microvascular parameters (central retinal artery/vein equivalent (μm)). We used continuous (in ng/mL) and categorical (deficient <20 ng/mL versus adequate >20 ng/mL) deseasonalized 25(OH)D₃ levels as exposure. Mixed effect and linear regression models were conducted. During their pregnancies, nearly 23% of the mothers had deficient vitamin D₃ levels. We did not find statistically significant associations between pregnancy vitamin D₃ levels and macro- and microvascular function markers across adolescence. However, subjects exposed to deficient vitamin D₃ levels showed a nonstatistically significant decrease in pulse wave velocity (β=-0.09 [95% CI, -0.19 to 0.01]) compared with those exposed to adequate levels. There was no evidence of a sex interaction.

Conclusions: Our findings show little evidence to support associations between low vitamin D levels during pregnancy and macro- or microvascular health parameters through early adolescence.

Background: The mechanisms driving the progression of moyamoya disease (MMD) remain unrecognized. There is evidence suggesting that genetic and environmental factors may be associated with intracranial artery stenosis. Here, we aimed to investigate the characteristics of infectious exposure and the association of the RNF213 (RING finger protein 213) variant and infectious burden (IB) with intracranial artery stenosis of MMD.

Methods and results: We prospectively recruited 275 patients with MMD. Participants underwent RNF213p.R4810K sequencing. Serum antibody titers of herpes simplex virus, cytomegalovirus, toxoplasma, rubella virus, and Epstein-Barr virus were assessed and combined into an IB score. The degree of intracranial artery stenosis was measured by using the Willis narrowing score (WNS), which was then dichotomized as mild and severe. Multivariate regression analyses were performed to analyze variables associated with severe WNS. Patients with the RNF213 variant had a higher risk of severe WNS than wild-type individuals (P=0.003). Patients with MMD with severe WNS showed an increased level of IB score (P<0.001). The RNF213 variant (odds ratio [OR], 2.832 [95% CI, 1.347-5.955]; P=0.006) and IB score (OR, 1.771 [95% CI, 1.286-2.439]; P<0.001) were significantly associated with severe WNS after adjusting for covariates. Furthermore, the associations between IB score and severe WNS were more prominent among patients with modifiable risk factors of elevated body mass index (P_interaction<0.001), triglycerides (P_interaction=0.011), and homocysteine (P_interaction=0.016).

Conclusions: This study outlined a perspective of the genetic-environmental interactions in the progression of MMD. The RNF213 variant and increased IB were associated with intracranial artery stenosis in MMD. The study will provide novel insights into the mechanism of disease progression, which may offer opportunities for early intervention of infectious exposure in MMD.

Heart failure (HF) and chronic kidney disease (CKD) frequently coexist, sharing significant overlap in prevalence and pathophysiological mechanisms. This coexistence, termed cardiorenal syndrome (CRS), often leads to anemia, which exacerbates both HF and CKD, thereby increasing morbidity and death. Managing anemia in CRS is complex due to conflicting guidelines and the multifactorial nature of the condition. Anemia in CRS is influenced by factors such as inadequate erythropoietin production, iron deficiency, reduced red blood cell life span, and chronic inflammation, which inhibit iron absorption and mobilization. This interplay of mechanisms worsens anemia, further aggravating HF and CKD. Anemia significantly impacts the prognosis of both HF and CKD, and recent trials have shown that hemoglobin increases, particularly with sodium-glucose cotransporter 2 inhibitors, can improve outcomes in patients with HF and CKD. Iron deficiency is also prevalent in both patients with HF and patients with CKD and is associated with poorer exercise capacity and a higher mortality rate. Guidelines for diagnosing and treating iron deficiency differ between HF and CKD. Furthermore, treatment of anemia in CRS is controversial: While sodium-glucose cotransporter 2 inhibitors and intravenous iron has shown consistent benefits in patients with CRS, normalization of hemoglobin with erythropoiesis-stimulating agents improves symptoms and quality of life but have not consistently demonstrated cardiovascular benefits. There are no definitive guidelines for anemia management in CRS. Treatment should address HF, CKD, and anemia concurrently. A proposed algorithm includes correcting iron deficiency, initiating sodium-glucose cotransporter 2 inhibitors, and considering erythropoiesis-stimulating agents if hemoglobin remains <10 g/dL. Further research is needed to optimize anemia management strategies in patients with CRS.

Atrial fibrillation (AF) is the most common sustained arrhythmia and associated with increased morbidity and mortality. Differences have been identified between medical care delivered in urban and rural settings, and rurality-based disparities may exist in AF care. We performed a systematic review investigating the effect of rurality on AF care and outcomes in the United States. PubMed was queried for entries on AF and rurality: ("atrial fibrillation" OR "atrial flutter") AND ("rural" OR "urban" OR "rurality" OR "metro" OR "metropolitan") AND ("united states" OR "US" OR "U.S.") published up to September 24, 2023. Anticoagulation, rhythm control, settings of care, outcomes, and all-cause mortality were reviewed in relevant studies. The search identified 395 total articles. After screening, 14 relevant articles were included in the review. These studies ranged from 1993 to 2020 and analyzed approximately 41.7 million AF patient encounters. The use of catheter ablation for AF per electrophysiologist was similar across the rural-urban spectrum. Patients with AF and rural residence were less likely to receive a direct oral anticoagulant and more likely to remain on warfarin (relative risk, 0.90 [95% CI, 0.88-0.92]). Patients in rural communities were less likely to receive non-emergent AF care (odds ratio [OR], 0.96 [95% CI, 0.93-0.98]). In-hospital mortality for patients with AF admitted to rural hospitals was higher than urban hospitals (OR, 1.19 [95% CI, 1.01-1.39)]. Measurable differences exist in both treatments and outcomes of patients with AF between rural and urban settings in the United States. These differences should inform future investigations and strategies to improve health in people with AF.