Transgender Women Exhibit a Distinct Stress Echocardiography Profile Compared With Age-Matched Cisgender Counterparts: The Mayo Clinic Women's Heart Clinic Experience.

BACKGROUND: Stress echocardiographic (SE) testing is an important modality in cardiovascular risk stratification and obstructive coronary artery disease assessment. Binary sex-based parameters are classically used for the interpretation of these studies, even among transgender women (TGW). Coronary artery disease is a leading cause of morbidity and mortality in this population. Yet, it remains unclear whether TGW exhibit a distinct stress testing profile from their cisgender counterparts. METHODS: Using a matched case-control study design, the authors compared the echocardiographic stress testing profiles of TGW (n = 43) with those of matched cisgender men (CGM; n = 84) and cisgender women (CGW; n = 86) at a single center. Relevant data, including demographics, comorbidities, and cardiac testing data, were manually extracted from the patients' charts. RESULTS: The prevalence of hypertension and dyslipidemia was similar between TGW and CGW and lower than that of CGM (P = .003 and P = .009, respectively). The majority of comorbidities and laboratory values were similar. On average, TGW had higher heart rates than CGM (P = .002) and had lower blood pressures than CGM and CGW (P < .05). TGW's double product and metabolic equivalents were similar to those among CGW and lower than those of CGM (P = .016 and P = .018, respectively). On echocardiography, left ventricular end-diastolic and end-systolic diameters among TGW were similar to those of CGW but lower than those of CGM (P = .023 and P = .018, respectively). Measures of systolic and diastolic function, except for exercise mitral valve E/e' ratio, which was lower in TGW than CGW (P = .029), were largely similar among the three groups. There was no difference in the wall motion score index, and therefore, no difference in the percentage of positive SE test results. CONCLUSIONS: This study shows, for the first time, that TGW have a SE profile that is distinct from that of their cisgender counterparts. Larger, multicenter, prospective studies are warranted to further characterize the SE profile of TGW.

Silent cerebral infarcts in patients with atrial fibrillation: Clinical implications of an imaging-adjusted CHA2DS2-VASc score.

BACKGROUND: The CHA2DS2-VASc score does not include silent infarcts on neuroimaging in stroke risk estimation for patients with atrial fibrillation (AF). The inclusion of silent infarcts into CHA2DS2-VASc scoring and its impact on stroke prophylaxis recommendations in patients with AF has not been previously studied. The present study sought to quantify the prevalence of silent infarcts in patients with AF and describe potential changes in management based on magnetic resonance imaging (MRI) findings. METHODS: Participants from the Mayo Clinic Study of Aging with AF and brain MRI were included. Silent infarcts were identified. "Standard" CHA2DS2-VASc scores were calculated for each subject based on clinical history alone and "imaging-adjusted" CHA2DS2-VASc scores based on evidence of cerebral infarction on MRI. Standard and imaging-adjusted scores were compared. RESULTS: One hundred and forty-seven participants (average age 77, 28% female) were identified with AF, MRI, and no clinical history of stroke. Overall, 41 (28%) patients had silent infarcts on MRI, corresponding with a 2-point increase in CHA2DS2-VASc score. Of these participants, only 39% (16/41) with silent infarct were on anticoagulation despite having standard CHA2DS2-VASc scores supportive of anticoagulation. After incorporating silent infarcts, 13% (19/147) would have an indication for periprocedural bridging compared to 0.6% (1/147) at baseline. CONCLUSIONS: Incorporation of silent infarcts into the CHA2DS2-VASc score may change the risk- -benefit ratio of anticoagulation. It may also increase the number of patients who would benefit from periprocedural bridging. Future research should examine whether an anticoagulation strategy based on imaging-adjusted CHA2DS2-VASc scores could result in a greater reduction of stroke and cognitive decline.

Transcatheter Mitral Valve Repair for Severe Functional Mitral Regurgitation and Cardiogenic Shock.

Patients with acute mitral regurgitation and cardiogenic shock have poor outcomes. Many patients do not qualify for surgery and are left with no treatment options. We present the case of a 76-year-old woman with severe mitral regurgitation, cardiogenic shock, and prohibitive surgical risk who was successfully treated with transcatheter mitral valve edge to edge repair. We also review the existing data that supports transcatheter mitral valve edge to edge repair in this setting.