Implications of Five Different Risk Models In Primary Prevention Guidelines.

BACKGROUND: A lack of consensus exists across guidelines as to which risk model should be used for the primary prevention of cardiovascular disease (CVD). Our objective was to determine potential improvements in the number needed to treat (NNT) and number of events prevented (NEP) using different risk models in patients eligible for risk stratification. METHODS: A retrospective observational cohort was assembled from primary care patients in Ontario, Canada between January 1st, 2010, to December 31st, 2014 and followed for up to 5 years. Risk estimation was undertaken in patients 40-75 years of age, without CVD, diabetes, or chronic kidney disease using the Framingham Risk Score (FRS), Pooled Cohort Equations (PCEs), a recalibrated FRS (R-FRS), Systematic Coronary Risk Evaluation 2 (SCORE2), and the low-risk region recalibrated SCORE2 (LR-SCORE2). RESULTS: The cohort consisted of 47,399 patients (59% women, mean age 54). The NNT with statins was lowest for SCORE2 at 40, followed by LR-SCORE2 at 41, R-FRS at 43, PCEs at 55, and FRS at 65. Models that selected for individuals with a lower NNT recommended statins to fewer, but higher risk patients. For instance, SCORE2 recommended statins to 7.9% of patients (5-year CVD incidence 5.92%). The FRS, however, recommended statins to 34.6% of patients (5-year CVD incidence 4.01%). Accordingly, the NEP was highest for the FRS at 406 and lowest for SCORE2 at 156. CONCLUSIONS: Newer models such as SCORE2 may improve statin allocation to higher risk groups with a lower NNT but prevent fewer events at the population level.

Evaluating a novel accelerated free-breathing late gadolinium enhancement imaging sequence for assessment of myocardial injury.

INTRODUCTION: Cardiac magnetic resonance imaging (MRI), including late gadolinium enhancement (LGE), plays an important role in the diagnosis and prognostication of ischemic and non-ischemic myocardial injury. Conventional LGE sequences require patients to perform multiple breath-holds and require long acquisition times. In this study, we compare image quality and assessment of myocardial LGE using an accelerated free-breathing sequence to the conventional standard-of-care sequence. METHODS: In this prospective cohort study, a total of 41 patients post Coronavirus 2019 (COVID-19) infection were included. Studies were performed on a 1.5 Tesla scanner with LGE imaging acquired using a conventional inversion recovery rapid gradient echo (conventional LGE) sequence followed by the novel accelerated free-breathing (FB-LGE) sequence. Image quality was visually scored (ordinal scale from 1 to 5) and compared between conventional and free-breathing sequences using the Wilcoxon rank sum test. Presence of per-segment LGE was identified according to the American Heart Association 16-segment myocardial model and compared across both conventional LGE and FB-LGE sequences using a two-sided chi-square test. The perpatient LGE extent was also evaluated using both sequences and compared using the Wilcoxon rank sum test. Interobserver variability in detection of per-segment LGE and per-patient LGE extent was evaluated using Cohen's kappa statistic and interclass correlation (ICC), respectively. RESULTS: The mean acquisition time for the FB-LGE sequence was 17 s compared to 413 s for the conventional LGE sequence (P < 0.001). Assessment of image quality was similar between both sequences (P = 0.19). There were no statistically significant differences in LGE assessed using the FB-LGE versus conventional LGE on a per-segment (P = 0.42) and per-patient (P = 0.06) basis. Interobserver variability in LGE assessment for FB-LGE was good for per-segment (= 0.71) and per-patient extent (ICC = 0.92) analyses. CONCLUSIONS: The accelerated FB-LGE sequence performed comparably to the conventional standard-of-care LGE sequence in a cohort of patients post COVID-19 infection in a fraction of the time and without the need for breath-holding. Such a sequence could impact clinical practice by increasing cardiac MRI throughput and accessibility for frail or acutely ill patients unable to perform breath-holding.

Comparing Costs of Noninvasive Cardiac Diagnostic Tests-a Population-Based Study.

INTRODUCTION: Noninvasive cardiac diagnostic tests (NITs) for the diagnosis of coronary artery disease have been estimated to cost >$3 billion annually in the United States alone and have recently undergone scrutiny over concerns of overuse. Consequently, comparing costs of different NIT testing strategies is of urgent importance to health care planning. METHODS: We utilized population-based administrative and clinical data from Ontario, Canada, to compare downstream costs between 4 available NIT testing strategies (graded exercise stress testing [GXT], stress echocardiography, cardiac computed tomography angiography [CCTA], and myocardial perfusion imaging [MPI] as well as no testing), among patients evaluated for chest pain. To compare costs among the tested (overall and by testing strategy) and nontested groups, we used a log-gamma generalized linear model to account for the skewed distribution of health care cost data, adjusting for relevant clinical covariates. RESULTS: A total of 2,340,699 patients were included in our cohort, of whom 481,170 (21%) patients received 1 of the 4 NITs. Among patients who received a NIT, 254,492 (53%) received a GXT as their initial test, 154,137 (32%) received MPI, 69,160 (14%) received a stress echo, and 3,381 (<1%) received a CCTA. After adjustment for differences in baseline patient characteristics, receipt of any NIT was associated with an approximate 12% reduction in downstream 1-year mean costs (cost ratio = 0.88; 95% CI, 0.87, 0.89) compared with those without any testing. Comparing the different testing strategies with no testing, both GXT (cost ratio = 0.80; 95% CI, 0.79-0.81) and stress echocardiography (cost ratio = 0.82; 95% CI, 0.81-0.83) were associated with the lower downstream costs, while both MPI (cost ratio = 1.26; 95% CI, 1.25, 1.27) and CCTA (cost ratio = 1.29; 95% CI, 1.23, 1.35) were associated with higher downstream costs. CONCLUSIONS: In a large population-based cohort consisting of >2 million people evaluated for chest pain, we report that receipt of noninvasive testing was associated with a 12% reduction in downstream costs when compared with no testing. Graded exercise stress testing and stress echocardiography were associated with the least downstream costs, whereas CCTA and MPI were associated with higher costs when compared with no testing. These findings may help inform testing decisions in chest pain patients.

Validation of the European SCORE2 models in a Canadian primary care cohort.

AIMS: Systematic Coronary Risk Evaluation Model 2 (SCORE2) was recently developed to predict atherosclerotic cardiovascular disease (ASCVD) in Europe. Whether these models could be used outside of Europe is not known. The objective of this study was to test the validity of SCORE2 in a large Canadian cohort. METHODS AND RESULTS: A primary care cohort of persons with routinely collected electronic medical record data from 1 January 2010 to 31 December 2014, in Ontario, Canada, was used for validation. The SCORE2 models for younger persons (YP) were applied to 57 409 individuals aged 40-69 while the models for older persons (OPs) were applied to 9885 individuals 70-89 years of age. Five-year ASCVD predictions from both the uncalibrated and low-risk region recalibrated SCORE2 models were evaluated. The C-statistic for SCORE2-YP was 0.74 in women and 0.69 in men. The uncalibrated SCORE2-YP overestimated risk by 17% in women and underestimated by 2% in men. In contrast, the low-risk region recalibrated model demonstrated worse calibration, overestimating risk by 100% in women and 36% in men. The C-statistic for SCORE2-OP was 0.64 and 0.62 in older women and men, respectively. The uncalibrated SCORE2-OP overestimated risk by more than 100% in both sexes. The low-risk region recalibrated model demonstrated improved calibration but still overestimated risk by 60% in women and 13% in men. CONCLUSION: The performance of SCORE2 to predict ASCVD risk in Canada varied by age group and depended on whether regional calibration was applied. This underscores the necessity for validation assessment of SCORE2 prior to implementation in new jurisdictions.

In this study, new tools [Systematic Coronary Risk Evaluation Model 2 (SCORE2)] that were developed across Europe to predict heart attack and stroke risk in healthy individuals were tested independently for the first time in a Canadian setting. Key findings are as follows:The accuracy of predictions from SCORE2 in Canadians depends on the age group considered and whether uncalibrated or recalibrated equations are being used.Independent assessment of tools such as SCORE2 remains useful prior to widespread implementation in new jurisdictions.

Impaired coronary microvascular reactivity in youth with bipolar disorder.

BACKGROUND: Cardiovascular disease (CVD) is excessively prevalent and premature in bipolar disorder (BD), even after controlling for traditional cardiovascular risk factors. The increased risk of CVD in BD may be subserved by microvascular dysfunction. We examined coronary microvascular function in relation to youth BD. METHODS: Participants were 86 youth, ages 13-20 years (n = 39 BD, n = 47 controls). Coronary microvascular reactivity (CMVR) was assessed using quantitative T2 magnetic resonance imaging during a validated breathing-paradigm. Quantitative T2 maps were acquired at baseline, following 60-s of hyperventilation, and every 10-s thereafter during a 40-s breath-hold. Left ventricular structure and function were evaluated based on 12-15 short- and long-axis cardiac-gated cine images. A linear mixed-effects model that controlled for age, sex, and body mass index assessed for between-group differences in CMVR (time-by-group interaction). RESULTS: The breathing-paradigm induced a significant time-related increase in T2 relaxation time for all participants (i.e. CMVR; ß = 0.36, p < 0.001). CMVR was significantly lower in BD v. controls (ß = -0.11, p = 0.002). Post-hoc analyses found lower T2 relaxation time in BD youth after 20-, 30-, and 40 s of breath-holding (d = 0.48, d = 0.72, d = 0.91, respectively; all pFDR < 0.01). Gross left ventricular structure and function (e.g. mass, ejection fraction) were within normal ranges and did not differ between groups. CONCLUSION: Youth with BD showed evidence of subclinically impaired coronary microvascular function, despite normal gross cardiac structure and function. These results converge with prior findings in adults with major depressive disorder and post-traumatic stress disorder. Future studies integrating larger samples, prospective follow-up, and blood-based biomarkers are warranted.

Development and Validation of the CANHEART Population-Based Laboratory Prediction Models for Atherosclerotic Cardiovascular Disease.

BACKGROUND: Prediction of atherosclerotic cardiovascular disease (ASCVD) in primary prevention assessments exclusively with laboratory results may facilitate automated risk reporting and improve uptake of preventive therapies. OBJECTIVE: To develop and validate sex-specific prediction models for ASCVD using age and routine laboratory tests and compare their performance with that of the pooled cohort equations (PCEs). DESIGN: Derivation and validation of the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) Lab Models. SETTING: Population-based cohort study in Ontario, Canada. PARTICIPANTS: A derivation and internal validation cohort of adults aged 40 to 75 years without cardiovascular disease from April 2009 to December 2015; an external validation cohort of primary care patients from January 2010 to December 2014. MEASUREMENTS: Age and laboratory predictors measured in the outpatient setting included serum total cholesterol, high-density lipoprotein cholesterol, triglycerides, hemoglobin, mean corpuscular volume, platelets, leukocytes, estimated glomerular filtration rate, and glucose. The ASCVD outcomes were defined as myocardial infarction, stroke, and death from ischemic heart or cerebrovascular disease within 5 years. RESULTS: Sex-specific models were developed and internally validated in 2 160 497 women and 1 833 147 men. They were well calibrated, with relative differences less than 1% between mean predicted and observed risk for both sexes. The c-statistic was 0.77 in women and 0.71 in men. External validation in 31 697 primary care patients showed a relative difference less than 14% and an absolute difference less than 0.3 percentage points in mean predicted and observed risks for both sexes. The c-statistics for the laboratory models were 0.72 for both sexes and were not statistically significantly different from those for the PCEs in women (change in c-statistic, -0.01 [95% CI, -0.03 to 0.01]) or men (change in c-statistic, -0.01 [CI, -0.04 to 0.02]). LIMITATION: Medication use was not available at the population level. CONCLUSION: The CANHEART Lab Models predict ASCVD with similar accuracy to more complex models, such as the PCEs. PRIMARY FUNDING SOURCE: Canadian Institutes of Health Research.

Association of Neighborhood-Level Marginalization With Health Care Use and Clinical Outcomes Following Hospital Discharge in Patients Who Underwent Coronary Catheterization for Acute Myocardial Infarction in a Single-Payer Health Care System.

BACKGROUND: Canadian data suggest that patients of lower socioeconomic status with acute myocardial infarction receive less beneficial therapy and have worse clinical outcomes, raising questions regarding care disparities even in universal health care systems. We assessed the contemporary association of marginalization with clinical outcomes and health services use. METHODS: Using clinical and administrative databases in Ontario, Canada, we conducted a population-based study of patients aged ≥65 years hospitalized for their first acute myocardial infarction between April 1, 2010 and March 1, 2019. Patients receiving cardiac catheterization and surviving 7 days postdischarge were included. Our primary exposure was neighborhood-level marginalization, a multidimensional socioeconomic status metric. Neighborhoods were categorized by quintile from Q1 (least marginalized) to Q5 (most marginalized). Our primary outcome was all-cause mortality. A proportional hazards regression model with a robust variance estimator was used to quantify the association of marginalization with outcomes, adjusting for risk factors, comorbidities, disease severity, and regional cardiologist supply. RESULTS: Among 53 841 patients (median age, 75 years; 39.1% female) from 20 640 neighborhoods, crude 1- and 3-year mortality rates were 7.7% and 17.2%, respectively. Patients in Q5 had no significant difference in 1-year mortality (hazard ratio [HR], 1.08 [95% CI, 0.95-1.22]), but greater mortality over 3 years (HR, 1.13 [95% CI, 1.03-1.22]) compared with Q1. Over 1 year, we observed differences between Q1 and Q5 in visits to primary care physicians (Q1, 96.7%; Q5, 93.7%) and cardiologists (Q1, 82.6%; Q5, 72.6%), as well as diagnostic testing. There were no differences in secondary prevention medications dispensed or medication adherence at 1 year. CONCLUSIONS: In older patients with acute myocardial infarction who survived to hospital discharge, those residing in the most marginalized neighborhoods had a greater long-term risk of mortality, less specialist care, and fewer diagnostic tests. Yet, there were no differences across socioeconomic status in prescription medication use and adherence.

Association of neighbourhood-level material deprivation with adverse outcomes and processes of care among patients with heart failure in a single-payer healthcare system: A population-based cohort study.

AIM: We studied the association between neighbourhood material deprivation, a metric estimating inability to attain basic material needs, with outcomes and processes of care among incident heart failure patients in a universal healthcare system. METHODS AND RESULTS: In a population-based retrospective study (2007-2019), we examined the association of material deprivation with 1-year all-cause mortality, cause-specific hospitalization, and 90-day processes of care. Using cause-specific hazards regression, we quantified the relative rate of events after multiple covariate adjustment, stratifying by age ≤65 or ≥66 years. Among 395 763 patients (median age 76 [interquartile range 66-84] years, 47% women), there was significant interaction between age and deprivation quintile for mortality/hospitalization outcomes (p ≤ 0.001). Younger residents (age ≤65 years) of the most versus least deprived neighbourhoods had higher hazards of all-cause death (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.10-1.29]) and cardiovascular hospitalization (HR 1.29 [95% CI 1.19-1.39]). Older individuals (≥66 years) in the most deprived neighbourhoods had significantly higher hazard of death (HR 1.11 [95% CI 1.08-1.14]) and cardiovascular hospitalization (HR 1.13 [95% CI 1.09-1.18]) compared to the least deprived. The magnitude of the association between deprivation and outcomes was amplified in the younger compared to the older age group. More deprived individuals in both age groups had a lower hazard of cardiology visits and advanced cardiac imaging (all p < 0.001), while the most deprived of younger ages were less likely to undergo implantable cardioverter-defibrillator/cardiac resynchronization therapy-pacemaker implantation (p = 0.023), compared to the least deprived. CONCLUSION: Patients with newly-diagnosed heart failure residing in the most deprived neighbourhoods had worse outcomes and reduced access to care than those less deprived.

Structured Cardiac Assessment Outperforms Visual Estimation in Novice Ultrasound Users: A Randomized Controlled Trial.

BACKGROUND: Two evidence-based techniques to determine left ventricular (LV) systolic function are taught in emergency medicine curricula. The first is a "structured approach," which qualitatively evaluates LV fractional shortening, E-point septal separation, and LV diameter. The other is the "eyeball method," which qualitatively estimates the LV ejection fraction (LVEF). OBJECTIVE: The aim of this study was to determine whether the structured approach or the eyeball method was superior for teaching LVEF estimation to novices. METHODS: Medical students were recruited to participate in our randomized controlled trial. Participants were randomized to the structured approach group or eyeball method group and completed one of two 15-min educational modules. Participants subsequently interpreted 12 echocardiogram clips to determine LV function. The primary outcome was the percentage of correct interpretations as determined by a cardiologist. RESULTS: Seventy-four participants were invited to participate and 32 completed the study (15 in the structured approach and 17 in the eyeball method groups). The majority (30 of 32 [93.75%]) were first- and second-year medical students with no prior ultrasound training. The mean time to complete the training was similar between groups (16.8 vs. 17.8 min; p = 0.66). The primary outcome of percent of correct interpretations was significantly higher in the structured approach group compared with the eyeball method group (88.9% vs. 73.0%; p < 0.01). CONCLUSIONS: Training novice ultrasound users in a structured qualitative LV assessment method was more effective than the eyeball method. Learners were able to achieve high accuracy after a brief training intervention. These results may help inform best practices for undergraduate ultrasound curriculum development.

Low Prevalence of Late Myocardial Injury on Cardiac MRI Following COVID-19 Infection.

BACKGROUND: The prevalence of abnormal cardiac magnetic resonance imaging (MRI) findings indicative of myocardial injury in patients who recovered from coronavirus disease 2019 (COVID-19) is currently unclear, with a high variability in the reported prevalence. PURPOSE: To assess the prevalence of myocardial injury after a COVID-19 infection. STUDY TYPE: Prospective, bicentric study. SUBJECTS: Seventy consecutive patients who recovered from COVID-19 and were previously hospitalized. Mean age was 57 years and 39% of the patients were female. Ten healthy controls and a comparator group of 75 nonischemic cardiomyopathy (NICM) patients were employed. FIELD STRENGTH/SEQUENCE: 1.5-T, steady-state free precession (SSFP) gradient-echo sequence, modified Look-Locker inversion recovery sequence with balanced SSFP readout, T2-prepared spiral readout sequence and a T1-weighted inversion recovery fast gradient-echo sequence was acquired ~4-5 months after recovery from COVID-19. ASSESSMENT: The SSFP sequence was utilized for the calculation of left and right ventricular volumes and ejection fractions (LVEF and RVEF) following manual endocardial contouring. T1 and T2 mapping was performed by pixel-wise exponential fitting, and T1 and T2 values were computed by manual contouring of the left ventricular endocardial and epicardial walls. Late gadolinium enhancement (LGE) images were graded qualitatively as LGE present or absent. STATISTICAL TESTS: T-tests and the χ2 or Fisher's exact tests were used to compare continuous and categorical variables respectively between the COVID-19 and NICM groups. Inter-rater agreement was evaluated by the intraclass correlation coefficient for continuous variables and Cohen's kappa test for LGE. RESULTS: Reduced RVEF occurred in 10%, LGE and elevated native T1 in 9%, reduced LVEF in 4%, and elevated T2 in 3% of COVID-19 patients, respectively. Patients with NICM had lower mean LVEF (41.6% ± 6% vs. 60% ± 7%), RVEF (46% ± 5% vs. 61% ± 9%), and a significantly higher prevalence of LGE (27% vs. 9%) when compared to those post-COVID-19. DATA CONCLUSION: Abnormal cardiac MRI findings may show a low prevalence in patients who recovered from COVID-19 and were previously hospitalized. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY: Stage 2.

Relationship of Neighbourhood Social Deprivation and Ethnicity on Access to Transcatheter and Surgical Aortic Valve Replacement: A Population-Level Study.

BACKGROUND: Wide geographic variation in access to transcatheter (TAVR) and surgical (SAVR) aortic valve replacement exists, but the impact of socioethnic factors on the geographic variation of AS management in Ontario, Canada, is unknown. METHODS: Neighbourhood rates of AS admissions, as a proxy for AS burden, and downstream TAVR and SAVR referrals and procedures were estimated for the 76 subregions in Ontario. To determine if the socioethnic geographic variations in referrals and procedures were concordant or discordant with AS burden, we calculated Pearson correlation coefficients to determine the relationship between AS burden and each of TAVR referrals, TAVR procedures, SAVR referrals, or SAVR procedures. We developed generalised linear models to determine the association between social deprivation indices captured in the Ontario Marginalization index and the rates of AS burden as well as TAVR/SAVR referral and procedures. RESULTS: There was wide geographic variation that was concordant between AS burden and the referral and procedure rates for TAVR and SAVR (correlation coefficients 0.86-0.96). Increased dependency was associated with higher rates of both TAVR/SAVR referrals and procedures (rate ratios 1.63-2.22). Neighbourhoods with a higher concentration of ethnic minorities were associated with lower AS burden as well as lower rates of both SAVR and TAVR referrals and procedures (rate ratios 0.57-0.85). CONCLUSIONS: An important ethnic gradient exists in AS burden and in both referral and completion of TAVR and SAVR in Ontario. Further research is necessary to understand if this gradient is appropriate or requires mitigation.

A Deep Learning Segmentation Pipeline for Cardiac T1 Mapping Using MRI Relaxation-based Synthetic Contrast Augmentation.

Purpose: To design and evaluate an automated deep learning method for segmentation and analysis of cardiac MRI T1 maps with use of synthetic T1-weighted images for MRI relaxation-based contrast augmentation. Materials and Methods: This retrospective study included MRI scans acquired between 2016 and 2019 from 100 patients (mean age ± SD, 55 years ± 13; 72 men) across various clinical abnormalities with use of a modified Look-Locker inversion recovery, or MOLLI, sequence to quantify native T1 (T1native), postcontrast T1 (T1post), and extracellular volume (ECV). Data were divided into training (n = 60) and internal (n = 40) test subsets. "Synthetic" T1-weighted images were generated from the T1 exponential inversion-recovery signal model at a range of optimal inversion times, yielding high blood-myocardium contrast, and were used for contrast-based image augmentation during training and testing of a convolutional neural network for myocardial segmentation. Automated segmentation, T1, and ECV were compared with experts with use of Dice similarity coefficients (DSCs), correlation coefficients, and Bland-Altman analysis. An external test dataset (n = 147) was used to assess model generalization. Results: Internal testing showed high myocardial DSC relative to experts (0.81 ± 0.08), which was similar to interobserver DSC (0.81 ± 0.08). Automated segmental measurements strongly correlated with experts (T1native, R = 0.87; T1post, R = 0.91; ECV, R = 0.92), which were similar to interobserver correlation (T1native, R = 0.86; T1post, R = 0.94; ECV, R = 0.95). External testing showed strong DSC (0.80 ± 0.09) and T1native correlation (R = 0.88) between automatic and expert analysis. Conclusion: This deep learning method leveraging synthetic contrast augmentation may provide accurate automated T1 and ECV analysis for cardiac MRI data acquired across different abnormalities, centers, scanners, and T1 sequences.Keywords: MRI, Cardiac, Tissue Characterization, Segmentation, Convolutional Neural Network, Deep Learning Algorithms, Machine Learning Algorithms, Supervised Learning Supplemental material is available for this article. © RSNA, 2022.

Utilization and impact of cardiovascular magnetic resonance on patient management in heart failure: insights from the SCMR Registry.

BACKGROUND: Cardiovascular magnetic resonance (CMR) is an important diagnostic test used in the evaluation of patients with heart failure (HF). However, the demographics and clinical characteristics of those undergoing CMR for evaluation of HF are unknown. Further, the impact of CMR on subsequent HF patient care is unclear. The goal of this study was to describe the characteristics of patients undergoing CMR for HF and to determine the extent to which CMR leads to changes in downstream patient management by comparing pre-CMR indications and post-CMR diagnoses. METHODS: We utilized the Society for Cardiovascular Magnetic Resonance (SCMR) Registry as our data source and abstracted data for patients undergoing CMR scanning for HF indications from 2013 to 2019. Descriptive statistics (percentages, proportions) were performed on key CMR and clinical variables of the patient population. The Fisher's exact test was used when comparing categorical variables. The Wilcoxon rank sum test was used to compare continuous variables. RESULTS: 3,837 patients were included in our study. 94% of the CMRs were performed in the United States with China, South Korea and India also contributing cases. Median age of HF patients was 59.3 years (IQR, 47.1, 68.3 years) with 67% of the scans occurring on women. Almost 2/3 of the patients were scanned on 3T CMR scanners. Overall, 49% of patients who underwent CMR scanning for HF had a change between the pre-test indication and post CMR diagnosis. 53% of patients undergoing scanning on 3T had a change between the pre-test indication and post CMR diagnosis when compared to 44% of patients who were scanned on 1.5T (p < 0.01). CONCLUSION: Our results suggest a potential impact of CMR scanning on downstream diagnosis of patients referred for CMR for HF, with a larger potential impact on those scanned on 3T CMR scanners.

TAVR in a Patient With Anomalous Origin and Course of the Left Main Coronary Artery.

In patients with anomalous coronary arteries with high-risk features, corrective cardiac surgery should be considered. We report the first case of transcatheter aortic valve replacement using a self-expanding Evolut valve, in a patient with a single coronary artery arising from the right coronary cusp and an intramural course of the left main. (Level of Difficulty: Intermediate.).

A Case of Recurrent Myocarditis After COVID-19 Vaccination, Due to Acute Myeloid Leukemia.

A 25-year-old man presented with chest pain and an elevated troponin level following COVID-19 vaccination. Despite initial response to nonsteroidal anti-inflammatory drugs, he developed a recurrent and relapsing course requiring multiple readmissions. Cardiac magnetic resonance imaging confirmed myocarditis. Due to progressing macrocytic anemia, he was eventually diagnosed with acute myeloid leukemia, thought to be the underlying driver of his recurrent and persistent myocarditis.

Nous relatons le cas d'un homme de 25 ans qui présentait une douleur thoracique et un taux élevé de troponine après avoir reçu un vaccin contre la COVID-19. Malgré la réponse initiale du patient aux anti-inflammatoires non stéroïdiens, le tableau clinique a évolué sur un mode récurrent et récidivant, et nécessité plusieurs réhospitalisations. L'imagerie par résonance magnétique cardiaque a permis de confirmer la présence d'une myocardite. Dans un contexte d'anémie macrocytaire évolutive, le patient a finalement reçu un diagnostic de leucémie myéloblastique aiguë, considérée comme le facteur sous-jacent de la myocardite récurrente et persistante dont il était atteint.

Population-Based Recalibration of the Framingham Risk Score and Pooled Cohort Equations.

BACKGROUND: The Framingham Risk Score (FRS) and Pooled Cohort Equations (PCEs) overestimate risk in many contemporary cohorts. OBJECTIVES: This study sought to determine if recalibration of these scores using contemporary population-level data improves risk stratification for statin therapy. METHODS: Five-year FRS and PCEs were recalibrated using a cohort of Ontario residents alive January 1, 2011, who were 30 to 79 years of age without cardiovascular disease. Scores were externally validated in a primary care cohort of routinely collected electronic medical record data from January 1, 2010, to December 31, 2014. The relative difference in mean predicted and observed risk, number of statins avoided, and number needed to treat with statins to reduce a cardiovascular event at 5 years were reported. RESULTS: The FRS was recalibrated in 6,938,971 Ontario residents (51.6% women, mean age 48 years) and validated in 71,450 individuals (56.1% women, mean age 52 years). Recalibration reduced overestimation from 109% to 49% for women and 131% to 32% for men. The recalibrated FRS was estimated to reduce statin prescriptions in up to 26 per 1,000 low-risk women and 80 per 1,000 low-risk men, as well as reduce the number needed to treat from 61 to 47 in women and from 53 to 41 in men. In contrast, after recalibration of the PCEs, risk remained overestimated by 217% in women and 128% in men. CONCLUSIONS: Recalibration is a feasible solution to improve risk prediction but is dependent on the model being used. Recalibration of the FRS but not the PCEs reduced overestimation and may improve utilization of statins.

Incidental Findings Among Youth Participating in Multimodal Imaging Research: Characteristics of Findings and Description of a Management Approach.

Research imaging in healthy and clinical youth populations yields incidental findings that require a management strategy. Our primary objective was to document the frequency and nature of incidental findings within a research group integrating multiple imaging modalities. A second objective was to describe the evolution of an approach to handling incidental findings. A case example was included to display the intricacies of some of these scenarios. Youth, ages 13-20 years, with bipolar disorder, familial risk for bipolar disorder, or healthy controls, obtained one or a combination of neuroimaging, cardio-thoracic imaging, retinal imaging, and carotid imaging. All images were systematically reviewed for incidental findings. Overall, of 223 participants (n = 102 healthy controls), 59% (n = 131) had a brain magnetic resonance imaging (MRI) incidental finding and 27% (n = 60) had at least one incidental brain finding requiring non-urgent follow-up. In addition, of 109 participants with chest/cardiac MRI and carotid ultrasound, 3% (n = 3) had chest findings, 2% (n = 2) had cardiac findings, and 1% (n = 1) had a carotid finding. Of 165 youth with retinal imaging, 1% (n = 2) had incidental findings. While the vast majority of these incidental findings were of a non-serious, non-urgent nature, there were noteworthy exceptions. Imaging research groups need a system that emphasizes the value of clinical review of research images and one that is collaborative and responsive in order to inform follow-up plans. Rating systems that have been developed and used in neuroimaging for the classification of incidental findings can be adapted for use in areas other than the brain. Regardless of severity, incidental findings may raise anxiety in youth participants and their parents. The optimal threshold is one that balances transparency with utility.

Relationship of frailty with excess mortality during the COVID-19 pandemic: a population-level study in Ontario, Canada.

BACKGROUND: There is a paucity of the literature on the relationship between frailty and excess mortality due to the COVID-19 pandemic. METHODS: The entire community-dwelling adult population of Ontario, Canada, as of January 1st, 2018, was identified using the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort. Residents of long-term care facilities were excluded. Frailty was categorized through the Johns Hopkins Adjusted Clinical Groups (ACG® System) frailty indicator. Follow-up was until December 31st, 2020, with March 11th, 2020, indicating the beginning of the COVID-19 pandemic. Using multivariable Cox models with patient age as the timescale, we determined the relationship between frailty status and pandemic period on all-cause mortality. We evaluated the modifier effect of frailty using both stratified models as well as incorporating an interaction between frailty and the pandemic period. RESULTS: We identified 11,481,391 persons in our cohort, of whom 3.2% were frail based on the ACG indicator. Crude mortality increased from 0.75 to 0.87% per 100 person years from the pre- to post-pandemic period, translating to ~ 13,800 excess deaths among the community-dwelling adult population of Ontario (HR 1.11 95% CI 1.09-1.11). Frailty was associated with a statistically significant increase in all-cause mortality (HR 3.02, 95% CI 2.99-3.06). However, all-cause mortality increased similarly during the pandemic in frail (aHR 1.13, 95% CI 1.09-1.16) and non-frail (aHR 1.15, 95% CI 1.13-1.17) persons. CONCLUSION: Although frailty was associated with greater mortality, frailty did not modify the excess mortality associated with the pandemic.