Race-Ethnic Differences of ST-Elevation Myocardial Infarction: Findings from a New York Health System Registry.

Background: Race and ethnicity are major considerations in the incidence, management, and long-term outcome of ST-elevation myocardial infarction (STEMI) in the United States, but there is limited existing comparative data. Methods: We assembled a registry in a health system serving Bronx, NY of STEMI patients from 2008-2014 and analyzed differences in presentation, treatment and mortality between Hispanic/Latino (H/L), non-Hispanic Black (NHB) and non-Hispanic White (NHW). Upon discharge post-treatment for STEMI, all patients were followed for a median of 4.4 years (interquartile range 2.5, 6.0). Out of 966 STEMI patients, mean age was 61 years, 46% were H/L and 65% were male. H/Ls and NHBs had a higher prevalence of hypertension and diabetes mellitus than their NHW counterparts, coinciding with a lower socioeconomic status (SES). Results: The number of critically diseased vessels found at cardiac catheterization and mean troponin levels did not vary by race-ethnicity; neither did the adjusted hazard ratios (HR) for death. However, age-sex adjusted rates of general hospital readmission were higher in NHBs vs NHWs (HR 1.30, P=.03). Age-sex adjusted cardiovascular readmissions rates were higher in H/Ls than NHWs (HR 1.42, P=.03). Age-sex adjusted heart failure readmissions were increased for both H/Ls (HR 2.14, P=.01) and NHBs (HR 2.12, P=.02) over NHWs. Conclusions: Among STEMI patients, a higher prevalence of modifiable cardiovascular risk factors and a lower SES was seen among NHBs and H/Ls compared to NHWs. Despite similar coronary disease severity and in-hospital death, NHBs and H/Ls had a greater risk of general, cardiovascular and heart failure readmissions post-STEMI compared to NHWs.

High PCO2 does not alter the thermal plasticity of developing Pacific herring embryos during a marine heatwave.

Forage fish tend to respond strongly to environmental variability and therefore may be particularly sensitive to marine climate stressors. We used controlled laboratory experiments to assess the vulnerability of Pacific herring (Clupea pallasii) embryos to the combined effects of high partial pressure of carbon dioxide (PCO2) and a simulated marine heatwave. The two PCO2 treatments reflected current conditions (∼550 µatm) and a future extreme level (∼2300 µatm). The dynamics of the heatwave (i.e. rate of onset: ∼0.85°C day-1; maximum intensity: +4.4°C) were modeled from the most extreme events detected by a long-term regional temperature dataset. Simultaneous exposure to these potential stressors did not affect embryo survival. However, the heatwave did elicit significant metabolic effects that included higher rates of routine metabolism (Q10=1.15-1.72), growth (Q10=1.87), rate of development to hatch (Q10=3.01) and yolk consumption (Q10=3.21), as well as a significant reduction in production efficiency (-10.8%) and a three-fold increase in the rate of developmental anomalies. By contrast, high PCO2 conditions produced comparatively small effects on vital rates, including a significant increase in time to hatch (+0.88 days) and a reduction in routine metabolic rate (-6.3%) under the ambient temperature regime only. We found no evidence that high PCO2 increased routine metabolic rate at either temperature. These results indicate that Pacific herring embryos possess sufficient physiological plasticity to cope with extreme seawater acidification under optimal and heatwave temperature conditions, although lingering metabolic inefficiencies induced by the heatwave may lead to important carryover effects in later life stages.

Are long-term growth responses to elevated pCO2 sex-specific in fish?

Whether marine fish will grow differently in future high pCO2 environments remains surprisingly uncertain. Long-term and whole-life cycle effects are particularly unknown, because such experiments are logistically challenging, space demanding, exclude long-lived species, and require controlled, restricted feeding regimes-otherwise increased consumption could mask potential growth effects. Here, we report on repeated, long-term, food-controlled experiments to rear large populations (>4,000 individuals total) of the experimental model and ecologically important forage fish Menidia menidia (Atlantic silverside) under contrasting temperature (17°, 24°, and 28°C) and pCO2 conditions (450 vs. ~2,200 µatm) from fertilization to ~ a third of this annual species' life span. Quantile analyses of trait distributions showed mostly negative effects of high pCO2 on long-term growth. At 17°C and 28°C, but not at 24°C, high pCO2 fish were significantly shorter [17°C: -5 to -9%; 28°C: -3%] and weighed less [17°C: -6 to -18%; 28°C: -8%] compared to ambient pCO2 fish. Reductions in fish weight were smaller than in length, which is why high pCO2 fish at 17°C consistently exhibited a higher Fulton's k (weight/length ratio). Notably, it took more than 100 days of rearing for statistically significant length differences to emerge between treatment populations, showing that cumulative, long-term CO2 effects could exist elsewhere but are easily missed by short experiments. Long-term rearing had another benefit: it allowed sexing the surviving fish, thereby enabling rare sex-specific analyses of trait distributions under contrasting CO2 environments. We found that female silversides grew faster than males, but there was no interaction between CO2 and sex, indicating that males and females were similarly affected by high pCO2. Because Atlantic silversides are known to exhibit temperature-dependent sex determination, we also analyzed sex ratios, revealing no evidence for CO2-dependent sex determination in this species.

A self-resolving, post-traumatic aortopulmonary shunt.

A 34-year-old Hispanic man sustained a stab wound to his chest complicated with hemopericardium and pericardial tamponade. He underwent emergent clamshell thoracotomy as well as repair to the pulmonary artery. A transthoracic echocardiogram showed no evidence of intracardiac shunt. Two months later, a new murmur was noted, with a transthoracic echocardiogram revealing high-velocity flow between the left coronary sinus and the main pulmonary artery, with which a coronary computed tomography angiogram concurred. A transesophageal echocardiogram was performed which revealed an aortopulmonic fistula from the left coronary sinus of Valsalva, approximately 1cm anterior to the ostium of the left main coronary artery, to the main pulmonary artery just distal to the pulmonic valve. Pulmonary insufficiency was minimal. The main pulmonary artery was dilated, measuring 3.2 cm by coronary computed tomography angiogram. Right ventricular systolic function was normal. Right and left heart catheterizations were performed to further assess hemodynamics and coronary anatomy; pulmonary artery pressures were 16/8 mm Hg. Aortopulmonary fistula was seen on aortogram. Surgery was deferred in view of lack of symptoms and uncertainty in its natural history in the setting of traumatic etiology. A repeat transthoracic echocardiogram at six-month follow-up showed spontaneous closure of the fistula.

Diel and tidal pCO2 × O2 fluctuations provide physiological refuge to early life stages of a coastal forage fish.

Coastal ecosystems experience substantial natural fluctuations in pCO2 and dissolved oxygen (DO) conditions on diel, tidal, seasonal and interannual timescales. Rising carbon dioxide emissions and anthropogenic nutrient input are expected to increase these pCO2 and DO cycles in severity and duration of acidification and hypoxia. How coastal marine organisms respond to natural pCO2 × DO variability and future climate change remains largely unknown. Here, we assess the impact of static and cycling pCO2 × DO conditions of various magnitudes and frequencies on early life survival and growth of an important coastal forage fish, Menidia menidia. Static low DO conditions severely decreased embryo survival, larval survival, time to 50% hatch, size at hatch and post-larval growth rates. Static elevated pCO2 did not affect most response traits, however, a synergistic negative effect did occur on embryo survival under hypoxic conditions (3.0 mg L-1). Cycling pCO2 × DO, however, reduced these negative effects of static conditions on all response traits with the magnitude of fluctuations influencing the extent of this reduction. This indicates that fluctuations in pCO2 and DO may benefit coastal organisms by providing periodic physiological refuge from stressful conditions, which could promote species adaptability to climate change.

High sensitivity of a keystone forage fish to elevated CO2 and temperature.

Sand lances of the genus Ammodytes are keystone forage fish in coastal ecosystems across the northern hemisphere. Because they directly support populations of higher trophic organisms such as whales, seabirds or tuna, the current lack of empirical data and, therefore, understanding about the climate sensitivity of sand lances represent a serious knowledge gap. Sand lances could be particularly susceptible to ocean warming and acidification because, in contrast to other tested fish species, they reproduce during boreal winter months, and their offspring develop slowly under relatively low and stable pCO2 conditions. Over the course of 2 years, we conducted factorial pCO2 × temperature exposure experiments on offspring of the northern sand lance Ammodytes dubius, a key forage species on the northwest Atlantic shelf. Wild, spawning-ripe adults were collected from Stellwagen Bank National Marine Sanctuary (Cape Cod, USA), and fertilized embryos were reared at three pCO2 conditions (400, 1000 and 2100 µatm) crossed with three temperatures (5, 7 and 10 ËšC). Exposure to future pCO2 conditions consistently resulted in severely reduced embryo survival. Sensitivity to elevated pCO2 was highest at 10 ËšC, resulting in up to an 89% reduction in hatching success between control and predicted end-of-century pCO2 conditions. Moreover, elevated pCO2 conditions delayed hatching, reduced remaining endogenous energy reserves at hatch and reduced embryonic growth. Our results suggest that the northern sand lance is exceptionally CO2-sensitive compared to other fish species. Whether other sand lance species with similar life history characteristics are equally CO2-sensitive is currently unknown. But the possibility is a conservation concern, because many boreal shelf ecosystems rely on sand lances and might therefore be more vulnerable to climate change than currently recognized. Our findings indicate that life history, spawning habitat, phenology and developmental rates mediate the divergent early life CO2 sensitivities among fish species.

Physiology-Guided Management of Serial/Diffuse Coronary Artery Disease.

PURPOSE OF REVIEW: Just over four decades ago, the management of coronary artery disease (CAD) witnessed a major breakthrough with the advent of minimally invasive treatment modalities like angioplasty followed by coronary stenting. Dr. Andreas Gruentzig pioneered this field in 1977 by adding a balloon to the Dotter catheter. From its inception, he was cognizant of the need for measuring pressures before and after balloon inflation in the treated coronary artery, device placement in the treated coronary artery. However, for decades subsequently, emphasis was placed primarily on preprocedural non-invasive tests and angiographic assessment of lesions based on percent diameter stenosis to guide therapeutic interventions. We review the progress of these physiologic advancements in management over the last 20 years, as well as the current state and prospects for the future. RECENT FINDINGS: More recently, clinical features heavily drive the decision whether or not to stent the diseased segment. A little more than two decades ago, a new approach to facilitate the decision whether or not to intervene on intermediate stenoses began to evolve. It became clear that other features besides angiography are important when considering benefit of mechanical intervention. The emphasis shifted to assessment of the physiological significance of coronary lesions, rather than solely anatomical identification of lesions at angiography. Physiological assessments have served to better discriminate potentially flow-limiting lesions, utilizing cutoff measurements to determine which patients would benefit from intervention in addition to medical therapy. We have found that there is still need for arrival at a consensus as regards the best practice in the context of physiological assessment of serial stenotic lesions, but that studies do show that techniques currently available are non-inferior to each other, and highly effective.

Ultrasound assessment of carotid arteries: Current concepts, methodologies, diagnostic criteria, and technological advancements.

Following cardiac disease and cancer, stroke continues to be the third leading cause of death and disability due to chronic disease in the developed world. Appropriate screening tools are integral to early detection and prevention of major cardiovascular events. In a carotid artery, the presence of increased intima-media thickness, plaque, or stenosis is associated with increased risk of a transient ischemic attack or a stroke. Carotid artery ultrasound remains a long-standing and reliable tool in the current armamentarium of diagnostic modalities used to assess vascular morbidity at an early stage. The procedure has, over the last two decades, undergone considerable upgrades in technology, approach, and utility. This review examines in detail the current state and usage of this integrally important means of extracranial cerebrovascular assessment.

Assessment of tricuspid valve by two- and three-dimensional echocardiography with special reference to percutaneous repair and prosthetic valve implantation procedures.

Moderate-to-severe tricuspid regurgitation affects approximately 1.6 million people in the United States. An estimated 8000 patients will undergo tricuspid surgery annually, leaving a large number of patients with this condition untreated. Many of these individuals who are not referred for surgery engender a large unmet clinical need; this may be primarily due to the surgical risk involved. In persons who are categorized as high-risk surgical candidates, percutaneous procedures present a viable alternative. The majority of developmental attention as regards percutaneous approaches has been focused on the aortic and mitral valves recently, but few data are available about the feasibility and efficacy of minimally invasive tricuspid valve treatment. We review the usefulness of two- and three-dimensional echocardiography in the assessment of the tricuspid valve with special reference to recent interest in percutaneous repair and prosthetic valve implantation procedures for severe functional tricuspid regurgitation.

A quantitative genetic approach to assess the evolutionary potential of a coastal marine fish to ocean acidification.

Assessing the potential of marine organisms to adapt genetically to increasing oceanic CO2 levels requires proxies such as heritability of fitness-related traits under ocean acidification (OA). We applied a quantitative genetic method to derive the first heritability estimate of survival under elevated CO2 conditions in a metazoan. Specifically, we reared offspring, selected from a wild coastal fish population (Atlantic silverside, Menidia menidia), at high CO2 conditions (∼2300 µatm) from fertilization to 15 days posthatch, which significantly reduced survival compared to controls. Perished and surviving offspring were quantitatively sampled and genotyped along with their parents, using eight polymorphic microsatellite loci, to reconstruct a parent-offspring pedigree and estimate variance components. Genetically related individuals were phenotypically more similar (i.e., survived similarly long at elevated CO2 conditions) than unrelated individuals, which translated into a significantly nonzero heritability (0.20 ± 0.07). The contribution of maternal effects was surprisingly small (0.05 ± 0.04) and nonsignificant. Survival among replicates was positively correlated with genetic diversity, particularly with observed heterozygosity. We conclude that early life survival of M. menidia under high CO2 levels has a significant additive genetic component that could elicit an evolutionary response to OA, depending on the strength and direction of future selection.