Negative Associations between Minority Stressors and Self-Reported Health Status among Sexual Minority Adults Living in Colombia.

Colombia has extensive laws prohibiting discrimination against sexual minority people. However, violence and discrimination toward sexual minorities are still frequent. While a growing body of research shows that sexual minority people experience elevated rates of discrimination and domestic abuse globally, little research has been conducted on these issues affecting sexual minorities in Colombia specifically. Using minority stress theory as a conceptual framework, this paper aims to fill this gap by examining the prevalence of experiencing intimate partner violence (IPV) and witnessed discrimination and the relationship of these stressors to self-reported health among a national sample of sexual minority Colombians. We found that bisexual individuals experienced higher rates of physical and sexual IPV, compared to lesbian and gay individuals. Additionally, sexual minority Colombians who experienced IPV and witnessed discrimination were more likely to report having poorer health, compared to those who had not. We discuss the implications of our findings for future research and clinicians working with sexual minority clients.

Echocardiographic changes and impact on clinical management in pregnant women with heart disease.

BACKGROUND: While guidelines recommend echocardiography for pregnant women with heart disease, there are limited data on its effect on clinical practice. In this study, we investigated pregnancy-associated echocardiographic changes and their impact on management. METHODS: This was a retrospective study of pregnant women with heart disease followed at an academic medical centre from 2016 to 2020. Data on maternal intrapartum and postpartum echocardiograms were collected and the impact on management analysed. RESULTS: 421 echocardiograms in 232 pregnancies were included in the study. The most common cardiac diagnosis was CHD (60.8% of pregnancies), followed by cardiomyopathy (9.9%). The frequency of baseline echocardiographic abnormalities varied by diagnosis, with abnormal right ventricular systolic pressure being the most common (15.0% of pregnancies in CHD and 23.1% of pregnancies with cardiomyopathy). 39.2% of the 189 follow-up echocardiograms had a significant change from the prior study, with the most common changes being declines in right ventricular function (4.2%) or left ventricular function (3.7%), and increases in right ventricular systolic pressure (5.3%) and aortic size (21.2%). 17.8% of echocardiograms resulted in a clinical management change, with the most common change being shorter interval follow-up. CONCLUSIONS: Echocardiographic changes in pregnant women with heart disease are common, in particular increases in aortic size. Echocardiography results in changes in management in a small but significant proportion of patients. Further studies are needed to determine how other factors, including patient access and resource allocation, factor into the use of echocardiography during pregnancy.

Myocardial contrast echocardiography assessment of perfusion abnormalities in hypertrophic cardiomyopathy.

BACKGROUND: Perfusion defects during stress can occur in hypertrophic cardiomyopathy (HCM) from either structural or functional abnormalities of the coronary microcirculation. In this study, vasodilator stress myocardial contrast echocardiography (MCE) was used to quantify and spatially characterize hyperemic myocardial blood flow (MBF) deficits in HCM. METHODS: Regadenoson stress MCE was performed in patients with septal-variant HCM (n = 17) and healthy control subjects (n = 15). The presence and spatial distribution (transmural diffuse, patchy, subendocardial) of perfusion defects was determined by semiquantitative analysis. Kinetic analysis of time-intensity data was used to quantify MBF, microvascular flux rate (ß), and microvascular blood volume. In patients undergoing septal myectomy (n = 3), MCE was repeated > 1 years after surgery.  RESULTS: In HCM subjects, perfusion defects during stress occurred in the septum in 80%, and in non-hypertrophied regions in 40%. The majority of septal defects (83%) were patchy or subendocardial, while 67% of non-hypertrophied defects were transmural and diffuse. On quantitative analysis, hyperemic MBF was approximately 50% lower (p < 0.001) in the hypertrophied and non-hypertrophied regions of those with HCM compared to controls, largely based on an inability to augment ß, although hypertrophic regions also had blood volume deficits. There was no correlation between hyperemic MBF and either percent fibrosis on magnetic resonance imaging or outflow gradient, yet those with higher degrees of fibrosis (≥ 5%) or severe gradients all had low septal MBF during regadenoson. Substantial improvement in hyperemic MBF was observed in two of the three subjects undergoing myectomy, both of whom had severe pre-surgical outflow gradients at rest. CONCLUSION: Perfusion defects on vasodilator MCE are common in HCM, particularly in those with extensive fibrosis, but have a different spatial pattern for the hypertrophied and non-hypertrophied segments, likely reflecting different contributions of functional and structural abnormalities. Improvement in hyperemic perfusion is possible in those undergoing septal myectomy to relieve obstruction.  TRIAL REGISTRATION: ClinicalTrials.gov NCT02560467.

Aortic adventitial thickness as a marker of aortic atherosclerosis, vascular stiffness, and vessel remodeling in systemic lupus erythematosus.

INTRODUCTION: There is limited human imaging data on the association of adventitial thickness (AT) with arterial disease. Systemic lupus erythematosus (SLE) is a prototypical disease model for studying markers of premature arterial disease. OBJECTIVE: To determine if increased aortic AT is associated with aortic atherosclerosis [increased intima media thickness (IMT) or plaques], stiffness [increased pressure-strain elastic modulus (PSEM)], and vessel remodeling. METHODS: In total, 70 SLE patients and 26 age- and sex-matched controls underwent transesophageal echocardiography (TEE). Two-dimensional guided M-mode images were obtained to assess AT, IMT, and plaques, and PSEM at the proximal, mid, and distal thoracic aorta. Images were interpreted by 3 observers unaware of the subjects' clinical data and each other's measurements. Abnormal aortic AT, IMT, and PSEM were defined as > 2SD above the overall mean values in controls and corresponded to > 1 mm, > 1 mm, and > 10.6 Pascal units, respectively. Plaques were defined as focal-protruding IMT > 50% of the surrounding vessel wall. RESULTS: Abnormal aortic AT, atherosclerosis, and abnormal stiffness were more frequent in SLE patients than in controls (all p ≤ 0.02). In SLE patients, abnormal AT combined with atherosclerosis was associated with larger aortic end-diastolic diameters than in controls (p ≤ 0.05). In SLE patients, aortic AT was greater in patients with atherosclerosis and in those with abnormal stiffness than in patients without these abnormalities (all p ≤ 0.02). In patients with abnormal AT, the degree of aortic stiffness was similar to those with atherosclerosis (p = 0.22). CONCLUSION: In patients with SLE, increased aortic AT is associated with aortic atherosclerosis, abnormal stiffness, and eccentric vessel remodeling. Key Points • In patients with SLE, abnormal aortic adventitial thickness is associated with aortic atherosclerosis, abnormal stiffness, and eccentric vessel remodeling. • In patients with SLE, aortic adventitial thickening may contribute to the extent of aortic atherosclerosis, abnormal aortic stiffness, and vessel remodeling. • To our knowledge, this is the first human imaging study to characterize the aortic adventitial layer and delineate its association with aortic disease.

Appropriateness of Percutaneous Coronary Interventions in Patients With Stable Coronary Artery Disease in US Department of Veterans Affairs Hospitals From 2013 to 2015.

Importance: In hospitals outside of the US Department of Veterans Affairs (VA) system, 1 in 10 percutaneous coronary interventions (PCIs) for stable coronary artery disease is considered rarely appropriate by the appropriate use criteria, with variation across hospitals. The appropriateness of PCIs in VA hospitals has not been documented. Objective: To characterize the appropriateness of PCIs in VA hospitals. Design, Setting, and Participants: This retrospective cohort study included patients with stable coronary artery disease undergoing elective PCI from November 1, 2013, to October 31, 2015, within the VA Clinical Assessment, Reporting, and Tracking Program, an operational program that includes 59 VA hospitals. Data were analyzed from March 1, 2019, to August 8, 2019. Exposures: Elective PCI at a VA hospital. Main Outcomes and Measures: Proportion of PCIs classified as appropriate, may be appropriate, or rarely appropriate; extent of hospital-level variation in rarely appropriate PCIs using criteria issued by cardiovascular professional societies in 2012. The extent of hospital-level variation in rates of rarely appropriate PCI was characterized using hospital proportions and random-effect logistic regression. Results: Among 2611 patients undergoing elective PCI (mean [SD] age, 66.3 [7.6] years; 2577 [98.7%] men) at 59 hospitals, a total of 778 PCIs (29.8%) were classified as appropriate, 1561 PCIs (59.8%) were classified as may be appropriate, and 272 PCIs (10.4%) were classified as rarely appropriate. Rarely appropriate PCIs were more commonly performed in patients who had low-risk stress test findings (220 patients [89.1%]), who were taking no (100 patients [36.8%]) or 1 (167 patients [61.4%]) antianginal medication, or who had 1 coronary artery stenosis (185 patients [68.0%]). The unadjusted hospital-level rates of rarely appropriate PCIs ranged from 0% to 28.6%, with a median (interquartile range) of 9.7% (6.3%-13.9%). Random-effect models yielded an estimated median (interquartile range) rate of rarely appropriate PCI of 10.4% (8.7%-12.3%). Conclusions and Relevance: These findings suggest that in VA practice, most PCIs for stable coronary artery disease were classified as appropriate or may be appropriate. However, 1 in 10 PCIs was classified as rarely appropriate, with variation across VA hospitals. Efforts to improve patient selection are needed.

Progression of atherosclerosis versus arterial stiffness with age within and between arteries in systemic lupus erythematosus.

The progression of atherosclerosis versus arterial stiffness with age within and between arteries has not been defined. Systemic lupus erythematosus (SLE) is a human model of accelerated arterial disease that may permit this determination. 76 SLE patients (69 women, age 37 ± 12 years) and 26 age-and-sex-matched controls (22 women, age 34 ± 11 years) underwent transesophageal echocardiography and carotid ultrasonography for assessment of atherosclerosis [plaques and intima-media thickening (IMT)] and arterial stiffness [increased pressure-strain elastic modulus (PSEM)] of the descending thoracic aorta and carotid arteries. Since IMT is highly associated with plaques, IMT was used as a marker of atherosclerosis to assess its progression in relation with age and PSEM. Aortic and carotid plaques, IMT, and PSEM were greater in patients than in controls (all p ≤ 0.05). Within the aorta and within the carotid arteries, the average percent increases per decade of age for IMT versus PSEM were similar in patients (8.55% versus 9.33% and 3.39% versus 2.46%, respectively) and controls (5.53% versus 6.60% and 4.75% versus 3.49%, respectively) (all p ≥ 0.58). However, in SLE patients, the average percent increases per decade of age for IMT and PSEM were higher in the aorta than in the carotid arteries (8.55% and 9.33% versus 3.39% and 2.46%, respectively, both p ≤ 0.03). In patients with SLE, atherosclerosis and arterial stiffness progress with age parallel to each other within arteries, but divergently between arteries with different anatomy and hemodynamics.

Correlation of neurocognitive function and brain lesion load on magnetic resonance imaging in systemic lupus erythematosus.

Neurocognitive dysfunction and brain injury on magnetic resonance imaging (MRI) are common in patients with systemic lupus erythematosus (SLE) and are associated with increased morbidity and mortality. However, brain MRI is expensive, is restricted by payers, and requires high expertise. Neurocognitive assessment is an easily available, safe, and inexpensive clinical tool that may select patients needing brain MRI. In this cross-sectional and controlled study, 76 SLE patients (69 women, age 37 ± 12 years) and 26 age and gender-matched healthy subjects (22 women, age 34 ± 11 years) underwent assessment of attention, memory, processing speed, executive function, motor function, and global neurocognitive function. All subjects underwent brain MRI with T1-weighted, fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging. Hemispheric and whole brain lesion load in cm3 were determined using semi-automated methods. Neurocognitive z-scores in all clinical domains were significantly lower and whole brain and right and left hemispheres brain lesion load were significantly greater in patients than in controls (all p ≤ 0.02). There was significant correlation between neurocognitive z-scores in all domains and whole brain lesion load: processing speed (r = - 0.46; p < 0.0001), attention (r = - 0.42; p < 0.001), memory (r = - 0.40; p = 0.0004), executive function (r = - 0.25; p = 0.03), motor function (r = - 0.25; p = 0.05), and global neurocognitive function (r = - 0.38; p = 0.006). Similar correlations were found for brain hemisphere lesion loads (all p ≤ 0.05). These correlations were strengthened when adjusted for glucocorticoid therapy and SLE disease activity index. Finally, global neurocognitive z-score and erythrosedimentation rate were the only independent predictors of whole brain lesion load (both p ≤ 0.007). Neurocognitive measures and brain lesion load are worse in SLE patients than in controls. In SLE patients, neurocognitive z-scores correlate negatively with and independently predict brain lesion load. Therefore, neurocognitive testing may be an effective clinical tool to select patients needing brain MRI.

Updates to Adherence to Hypertension Medications.

PURPOSE OF REVIEW: The purpose of this review is to discuss recent studies that have described approaches or interventions to improve hypertension medication adherence and to suggest how providers can integrate evidenced-based approaches into routine clinical care to improve medication adherence and blood pressure control. RECENT FINDINGS: Factors that can impact medication include patient-related factors, social- and economic-related factors, health system/health care team-related factors, and therapy-related factors. Overall, a multifaceted approach is needed to improve medication adherence. Important components include (1) patient education on hypertension, its treatment modalities and its long-term complications; and (2) patient engagement building on the foundation of education. The various interventions tested have engaged patients through interactive educational sessions, health coaching, motivational interviewing, stage of change behavioral counseling, and pharmacist hypertension management. Strategies utilizing patient education and engagement are needed to improve medication adherence and blood pressure control.

Takotsubo Cardiomyopathy With a Rapidly Resolved Left Ventricular Thrombus.

This article presents the case of a 53-year-old man who presented with acute right superficial femoral and popliteal arterial thrombosis for which he underwent an emergent uncomplicated thrombectomy. He denied preceding cardiovascular or neurologic symptomatology and had no history of coronary or peripheral arterial disease, trauma, hypercoagulability, or malignancy. However, he reported having several days of intense emotional stress prior to presentation. His cardiac exam was normal, his electrocardiogram showed normal sinus rhythm and nonspecific ST-T wave abnormalities, and his troponin levels were normal. Transthoracic echocardiography (TTE) revealed a large (2.4 × 2 cm) apical left ventricle (LV) thrombus, LV apical akinesis, and LV ejection fraction of 40% to 45%. Coronary angiography revealed only luminal irregularities. A repeat TTE performed 3 days after initiating unfractionated heparin revealed complete resolution of the LV thrombus. The patient had an uneventful clinical course and was discharged home in stable condition on oral anticoagulants. The lower incidence of LV thrombus in takotsubo cardiomyopathy (TC) of 1.3% in comparison to 4% to 8% in acute myocardial infarction due to coronary artery disease in the current era of early reperfusion may be explained by the lower extent of ischemic myocardial necrosis associated with TC. This case suggests that the lower extent of myocardial necrosis in TC may also lead to faster resolution of LV thrombus. Therefore, earlier follow-up with TTE (within 2 weeks) and shorter duration of anticoagulation (<3 months) may be considered in patients with TC complicated by LV thrombus formation with or without systemic embolism.

Lambl's Excrescences: Association with Cerebrovascular Disease and Pathogenesis.

BACKGROUND: Lambl's excrescences (LEx) are detected by transesophageal echocardiography (TEE) and are characterized as thin, elongated, and hypermobile structures located at the leaflets' coaptation point of the heart valves. The association of LEx with cerebrovascular disease (CVD) is still undefined and yet patients with LEx and suspected CVD receive unproven effective antiplatelet or anticoagulant therapy or even undergo valve surgery. Also, the association of LEx with aging and atherogenic, inflammatory, or thrombogenic parameters has not been reported. METHODS: Seventy-seven patients with systemic lupus erythematosus (SLE) (71 women, age 37 ± 12 years) and 26 age- and sex-matched healthy controls (22 women, age 34 ± 11 years) prospectively underwent routine history and physical exam, transcranial Doppler, brain MRI, TEE, carotid duplex, and clinical and laboratory evaluations of atherogenesis, inflammation, platelet activity, coagulation, and fibrinolysis. Subjects without stroke/TIA on enrollment (with and without LEx) had a median follow-up of 57 months. RESULTS: On enrollment, 33 (43%) of 77 patients had CVD manifested as acute stroke/TIA (23 patients), cerebromicroembolism by transcranial Doppler (17 patients), or cerebral infarcts by MRI (14 patients). Mitral or aortic valve LEx were equally frequent in healthy controls (46%) as in patients with and without any CVD (39 and 43%), stroke/TIA (35 and 43%), cerebromicroembolism (41 and 42%), or cerebral infarcts (36 and 43%) (all p ≥ 0.72). Also, other mechanisms for CVD other than LEx such as Libman-Sacks vegetations, patent foramen ovale or interatrial septal aneurysm, aortic or carotid atherosclerosis, or thrombogenesis were found in ≥94% of patients with CVD. In addition, 36 subjects with and 44 without LEx had similar low incidence of stroke/TIA (1 (1.3%) and 2 (2.5%), respectively, p = 1.0) during follow-up. Finally, LEx were not associated with aging, atherogenic risk factors, atherosclerosis, inflammation, or thrombogenesis. CONCLUSIONS: In this study, LEx are similarly prevalent in healthy controls and SLE patients, are not associated with CVD, and are not associated with pathogenic risk factors. Therefore, the study findings suggest that LEx may not be cardioembolic substrates, may not represent pathologic valve structures, and may not require therapy.

Successful mortality reduction and control of comorbidities in patients with acromegaly followed at a highly specialized multidisciplinary clinic.

CONTEXT: Acromegaly is usually due to the excessive secretion of GH by a pituitary adenoma. It is frequently accompanied by comorbidities that compromise quality of life and results in elevated mortality rates. OBJECTIVE: To evaluate mortality and morbidity in patients with acromegaly receiving multimodal care. SETTING: Tertiary care center. DESIGN, PATIENTS, AND METHODS: Retrospective evaluation of 442 patients (65.4% women; mean age, 43.5 ± 13.1 y) followed for a median of 6 years (interquartile range [IQR], 3-10). RESULTS: Twenty-two patients died during the study period (4.9%), representing a total standardized mortality ratio (SMR) of 0.72 (95% confidence interval [CI], 0.41-1.03). Standardized mortality ratios were 1.5 and 0.44 for patients whose last GH was above and below 2.5 ng/mL, respectively; 1.17 and 0.16 for those whose last GH was above and below 1 ng/mL, respectively; and 0.94 and 0.46 for those whose last IGF-1 was above and below 1.2 times the upper limit of normal (ULN), respectively. The prevalence of diabetes mellitus, hypertension, heart disease, and cancer was 30%, 35%, 8%, and 4.7%, respectively. The most common cause of death was cancer. On multivariate analysis, diabetes, heart disease, and cancer were related to a baseline GH > 10 ng/mL; the presence of cancer and the last IGF-1 were significant predictors of mortality. Survival decreased as the latest GH levels increased from < 1 ng/mL to > 5 ng/mL and as IGF-1 increased from < 1.2 to > 2 times the ULN. CONCLUSIONS: Mortality in acromegaly can be successfully reduced, provided patients are treated using a multimodal approach with careful management of comorbidities.

Aortic Atherosclerosis in Systemic Lupus Erythematosus.

Aortic atherosclerosis (AoA) defined as intima-media thickening or plaques and aortic stiffness (AoS) also considered an atherosclerotic process and defined as decreased vessel distensibility (higher pulse pressure to achieve similar degree of vessel distension) are common in patients with SLE. Immune-mediated inflammation, thrombogenesis, traditional atherogenic factors, and therapy-related metabolic abnormalities are the main pathogenic factors of AoA and AoS. Pathology of AoA and AoS suggests an initial subclinical endothelialitis or vasculitis, which is exacerbated by thrombogenesis and atherogenic factors and ultimately resulting in AoA and AoS. Computed tomography (CT) for detection of arterial wall calcifications and arterial tonometry for detection of increased arterial pulse wave velocity are the most common diagnostic methods for detecting AoA and AoS, respectively. MRI may become a more applicable and accurate technique than CT. Although transesophageal echocardiography accurately detects earlier and advanced stages of AoA and AoS, it is semi-invasive and cannot be used as a screening method. Although imaging techniques demonstrate highly variable prevalence rates, on average about one third of adult SLE patients may have AoA or AoS. Age at SLE diagnosis; SLE duration; activity and damage; corticosteroid therapy; metabolic syndrome; chronic kidney disease; and mitral annular calcification are common independent predictors of AoA and AoS. Also, AoA and AoS are highly associated with carotid and coronary atherosclerosis. Earlier stages of AoA and AoS are usually subclinical. However, earlier stages of disease may be causally related or contribute to peripheral or cerebral embolism, pre-hypertension and hypertension, and increased left ventricular afterload resulting in left ventricular hypertrophy and diastolic dysfunction. Later stages of disease predisposes to visceral ischemia, aortic aneurysms and aortic dissection. Even earlier stages of AoA and AoS have been associated with increased cardiovascular and cerebrovascular morbidity and mortality of SLE patients. Aggressive non-steroidal immunosuppressive therapy and non-pharmacologic and pharmacologic interventions for control of atherogenic risk factors may prevent the development or progression of AoA and AoS and may decrease cardiovascular and cerebrovascular morbidity and mortality in SLE.