Background:Elevated perceived stress is associated with adverse outcomes following myocardial infarction (MI) and may account for poorer recovery among women vs men. Objectives:This randomized controlled trial tested effects of a mindfulness-based intervention on stress levels among women with MI. Methods:Women with elevated stress (Perceived Stress Scale [PSS-4]≥6) at least 2 months after MI were enrolled from 12 hospitals in the United States and Canada and via community advertising. Participants were randomized to a remotely delivered mindfulness intervention (MBCT-Brief) or heart disease education, both 8 weeks long. Follow-up was 6 months. Changes in stress (PSS-10; primary outcome) and secondary outcomes (depressive symptoms, anxiety, quality of life, disease-specific health status, actigraphy-assessed sleep) were compared between groups. Results:The sample included 130 women with MI (mean age 59.8 ± 12.8 years, 34% racial/ethnic minorities). In intention-to-treat analysis, PSS-10 scores declined in the MBCT-Brief arm (-0.52 [95% CI: -0.77 to -0.28]) but not the heart disease education arm (-0.19 [95% CI: -0.45 to 0.06]; group×time interaction P = 0.070). The effect was stronger in per-protocol analysis of participants who completed ≥4 intervention sessions (P = 0.049). There were no significant differences in secondary outcomes in intention-to-treat or per-protocol analyses. Within the MBCT-Brief arm, more frequent mindfulness practice was associated with greater reductions in stress (P = 0.007), depressive symptoms (P = 0.017), and anxiety (P = 0.036). Conclusions:MBCT-Brief was associated with greater 6-month reductions in stress than an active control among adherent participants. More frequent mindfulness practice was associated with greater improvements in psychological outcomes. Strategies to engage women with MI in mindfulness training and support regular home practice may enhance these effects.

Cardiovascular disease is the leading cause of maternal mortality in the United States. Pregnancy is associated with increased risk of acute myocardial infarction (AMI) and outcomes of pregnancy-associated AMI (PAMI) are poor. Spontaneous coronary artery dissection is the most common cause of PAMI. Pregnancy is not a contraindication to invasive coronary angiography or percutaneous coronary intervention (PCI) when indicated. When coronary angiography or PCI is needed, measures should be taken to minimize procedural and anesthetic risks specific to pregnancy. Multidisciplinary collaboration is imperative to optimizing maternal and fetal outcomes associated with PAMI.

Background:There are limited data on diversity and discrimination against interventional cardiologists (ICs). Methods:We performed an online, anonymous, international survey of interventional cardiologists on their perceptions of diversity and discrimination in their field. Results:A total of 445 ICs participated in the survey. The median age of participants was 46 to 50 years and most (60%) practice in the United States. Among the respondents, 13% identified as women, while 31% identified as Asian, 10% as Latino, and 3.2% as Black/African American. Women ICs were less likely to be married (62% vs 92%; P < .001) or have children (48% vs 87%; P < .001). Women, non-native English speakers, and non-white individuals had a higher likelihood of reporting discrimination from patients/families, peers, supervisors, support staff, and nursing staff, compared with men, native English speakers, and non-Hispanic white individuals, respectively. Women were less satisfied with the level of gender diversity in their workplace (25% vs 45%; P = .015) and were more likely to believe that women physicians have fewer opportunities in the field of IC compared with men (69% vs 35%; P < .001). Non-white individuals were more likely to believe that their race/ethnicity may impede the progress of their career (54% vs 15%; P < .001), that their race/ethnicity negatively impacted their fellowship prospects/acceptance (35% vs 11%; P < .001), and that their religion negatively impacted their fellowship prospects/acceptance (17% vs 4%; P = .003). Several participants (41%) expressed concerns that diversity, equity, and inclusion initiatives might result in unintended consequences. Conclusions:Our survey suggests that ICs perceive high rates of discrimination in their field.

Cardiogenic shock (CS) is a severe complication of peripartum cardiomyopathy (PPCM). Patients with deteriorating CS often require temporary mechanical circulatory support. In PPCM, this can be used as a bridge to postpartum recovery or bridge to decision. The outcomes are unclear, especially if prolonged utilization is required. We present a case series of three patients with PPCM in deteriorating CS who were successfully supported with a ventricular assist device or veno-arterial extracorporeal membrane oxygenation as a bridge to postpartum recovery.

Electrophysiological and interventional procedures have been increasingly used to reduce morbidity and mortality in patients experiencing cardiovascular diseases. Although antithrombotic therapies are critical to reduce the risk of stroke or other thromboembolic events, they can nonetheless increase the bleeding hazard. This is even more true in an aging population undergoing cardiac procedures in which the combination of oral anticoagulants and antiplatelet therapies would further increase the hemorrhagic risk. Hence, the timing, dose, and combination of antithrombotic therapies should be carefully chosen in each case. However, the maze of society guidelines and consensus documents published so far have progressively led to a hazier scenario in this setting. Aim of this review is to provide—in a single document—a quick, evidenced-based practical summary of the antithrombotic approaches used in different cardiac electrophysiology and interventional procedures to guide the busy clinician and the cardiac proceduralist in their everyday practice.

The United States has the highest maternal mortality in the developed world with cardiovascular disease as the leading cause of pregnancy-related deaths. In response to this, the emerging subspecialty of cardio-obstetrics has been growing over the past decade. Cardiologists with training and expertise in caring for patients with cardiovascular disease in pregnancy are essential to provide effective, comprehensive, multidisciplinary, and high-quality care for this vulnerable population. This document provides a blueprint on incorporation of cardio-obstetrics training into cardiovascular disease fellowship programs to improve knowledge, skill, and expertise among cardiologists caring for these patients, with the goal of improving maternal and fetal outcomes.

BackgroundPrevious studies have demonstrated an increased risk of cardiovascular disease (CVD) in women with a history of pregnancy loss. Less is known about whether pregnancy loss is associated with age at the onset of CVD, but this is a question of interest, as a demonstrated association of pregnancy loss with early-onset CVD may provide clues to the biological basis of the association, as well as having implications for clinical care. We conducted an age-stratified analysis of pregnancy loss history and incident CVD in a large cohort of postmenopausal women aged 50–79 years old.MethodsAssociations between a history of pregnancy loss and incident CVD were examined among participants in the Women's Health Initiative Observational Study. Exposures were any history of pregnancy loss (miscarriage and/or stillbirth), recurrent (2+) loss, and a history of stillbirth. Logistic regression analyses were used to examine associations between pregnancy loss and incident CVD within 5 years of study entry in three age strata (50–59, 69–69, and 70–79). Outcomes of interest were total CVD, coronary heart disease (CHD), congestive heart failure, and stroke. To assess the risk of early onset CVD, Cox proportional hazard regression was used to examine incident CVD before the age of 60 in a subset of subjects aged 50–59 at study entry.ResultsAfter adjustment for cardiovascular risk factors, a history of stillbirth was associated with an elevated risk of all cardiovascular outcomes in the study cohort within 5 years of study entry. Interactions between age and pregnancy loss exposures were not significant for any cardiovascular outcome; however, age-stratified analyses demonstrated an association between a history of stillbirth and risk of incident CVD within 5 years in all age groups, with the highest point estimate seen in women aged 50–59 (OR 1.99; 95% CI, 1.16–3.43). Additionally, stillbirth was associated with incident CHD among women aged 50–59 (OR 3.12; 95% CI, 1.33–7.29) and 60–69 (OR 2.06; 95% CI, 1.24–3.43) and with incident heart failure and stroke among women aged 70–79. Among women aged 50–59 with a history of stillbirth, a non-significantly elevated hazard ratio was observed for heart failure before the age of 60 (HR 2.93, 95% CI, 0.96–6.64).ConclusionsHistory of stillbirth was strongly associated with a risk of cardiovascular outcomes within 5 years of baseline in a cohort of postmenopausal women aged 50–79. History of pregnancy loss, and of stillbirth in particular, might be a clinically useful marker of cardiovascular disease risk in women.

•The treatment of long coronary lesions is challenging and encountered frequently•The availability of 48-mm drug-eluting stents in the United States has been limited•SPIRIT 48 assessed the safety/efficacy of XIENCE 48-mm in diffuse coronary disease•XIENCE 48-mm was associated with few adverse events and high procedural success

Background:Obstructive coronary artery disease (CAD) is common in patients with severe symptomatic aortic stenosis. The management and impact of obstructive CAD in patients undergoing transcatheter aortic valve replacement (TAVR) have not been fully evaluated. We aimed to determine the patient characteristics and clinical outcomes among veterans undergoing TAVR with and without obstructive CAD and to determine temporal trends and association of pre-TAVR percutaneous coronary intervention (PCI) with clinical outcomes. Methods:We identified all patients who underwent TAVR from 2012 to 2021 in the VA Health Care System. The sample population was divided into patients with and without obstructive CAD and further stratified by coronary intervention status 1 year prior to TAVR. The primary outcome was 1-year all-cause mortality, and the secondary outcome was major bleeding. Results:During the study period, 759 patients underwent TAVR, and 282 (37%) had obstructive CAD. Obstructive CAD was associated with higher 1-year mortality (15.6% vs 7.1%; P < .01) after TAVR. The rate of PCI prior to TAVR increased from 2012 until 2016, after which it steadily declined such that 144 patients (51%) underwent PCI pre-TAVR during the entire study period. There was no difference in 1-year mortality (16.0% vs 15.2%; P = .89) or bleeding (16.7% vs 12.3%; P = .33) between patients who underwent or did not undergo pre-TAVR PCI. Conclusions:Among veterans undergoing TAVR, the presence of obstructive CAD is associated with higher mortality though pre-TAVR coronary intervention is not associated with improved outcomes. Further studies could identify a subset of patients who may benefit from coronary revascularization prior to TAVR.

PCI for long, diffuse lesions may often require multiple stents. Concerns remain with overlapping multiple stents, including geographic miss involving two stents, increase in procedural time, contrast use, radiation dose and procedural cost. The availability and use of longer stents can circumvent the need for overlapping stents and facilitate interventional management of patients with diffuse coronary artery lesions. The prospective, single-arm, open-label SPIRIT 48 trial evaluated the safety and efficacy of Abbott's next-generation drug-eluting stent 48 mm everolimus-eluting coronary stent system (EECSS) (called "ABT NG DES 48") or XIENCE Skypoint 48 IDE, in subjects with coronary artery disease with long de novo native coronary lesions. SPIRIT 48 enrolled 107 patients at 25 sites in 3 countries. Patients enrolled were required to have one target lesion that would be treated with ABT NG DES 48. The primary endpoint of this study was target lesion failure (TLF; composite of cardiac death, target-vessel MI or clinically indicated TLR) at 1-year follow-up that was compared to a pre-specified performance goal (PG) of 20% and adjudicated by an independent Clinical Events Committee (CEC). This study recently completed its 1-year follow-up. SPIRIT 48 achieved a device success rate of 97.2%, which reflects the deliverability of ABT NG DES 48. In addition, a rate of 5.8% (6/104 subjects) for cardiac death/all MI at 1yr attests to the safety of this device. Importantly, SPIRIT 48 met its primary endpoint, with a TLF rate of 5.7%, and the upper bound of 95% CI at 9.5%, which was significantly lower than the pre-specified PG. In addition, definite/probable device thrombosis at 1 year occurred in only 1 subject treated with ABT NG DES 48 (1.0%). This study obtained robust data collected through the peak of the COVID-19 pandemic. The primary endpoint data obtained at 1-year follow-up from the SPIRIT 48 trial presents strong evidence supporting the deliverability, effectiveness, and safety of XIENCE Skypoint 48mm drug-eluting stent in treating long de novo coronary lesions.

The United States has the highest maternal mortality in the developed world with cardiovascular disease as the leading cause of pregnancy-related deaths. In response to this, the emerging subspecialty of cardio-obstetrics has been growing over the past decade. Cardiologists with training and expertise in caring for patients with cardiovascular disease in pregnancy are essential to provide effective, comprehensive, multidisciplinary, and high-quality care for this vulnerable population. This document provides a blueprint on incorporation of cardio-obstetrics training into cardiovascular disease fellowship programs to improve knowledge, skill, and expertise among cardiologists caring for these patients, with the goal of improving maternal and fetal outcomes.

Angina with nonobstructive coronary arteries (ANOCA) is increasingly recognized and may affect nearly one-half of patients undergoing invasive coronary angiography for suspected ischemic heart disease. This working diagnosis encompasses coronary microvascular dysfunction, microvascular and epicardial spasm, myocardial bridging, and other occult coronary abnormalities. Patients with ANOCA often face a high burden of symptoms and may experience repeated presentations to multiple medical providers before receiving a diagnosis. Given the challenges of establishing a diagnosis, patients with ANOCA frequently experience invalidation and recidivism, possibly leading to anxiety and depression. Advances in scientific knowledge and diagnostic testing now allow for routine evaluation of ANOCA noninvasively and in the cardiac catheterization laboratory with coronary function testing (CFT). CFT includes diagnostic coronary angiography, assessment of coronary flow reserve and microcirculatory resistance, provocative testing for endothelial dysfunction and coronary vasospasm, and intravascular imaging for identification of myocardial bridging, with hemodynamic assessment as needed.

Cardiovascular multidisciplinary heart teams (MDHTs) have evolved significantly over the past decade. These teams play a central role in the treatment of a wide array of cardiovascular diseases affecting interventional cardiology, cardiac surgery, interventional imaging, advanced heart failure, adult congenital heart disease, cardio-oncology, and cardio-obstetrics. To meet the specific needs of both patients and heart programs, the composition and function of cardiovascular MDHTs have had to adapt and evolve. Although lessons have been learned from multidisciplinary cancer care, best practices for the operation of cardiovascular MDHTs have yet to be defined, and the evidence base supporting their effectiveness is limited. This expert panel review discusses the history and evolution of cardiovascular MDHTs, their composition and role in treating patients across a broad spectrum of disciplines, basic tenets for successful operation, and the future challenges facing them.

The “fourth trimester” in cardio-obstetrics refers to pregnancy as a predictor of future cardiovascular disease and to the importance of optimizing maternal health in the postpartum period. Adverse pregnancy outcomes (APOs), which include the hypertensive disorders of pregnancy (HDPs), gestational diabetes, preterm delivery, small-for-gestational-age births, and pregnancy loss, offer a window into a woman’s future cardiovascular health. APOs are associated with accelerated future development of cardiovascular risk factors and cardiovascular disease (CVD). For example, HDPs are associated with an increased risk of both cardiovascular risk factors (e.g., hypertension, diabetes) and cardiovascular disease, including atherosclerotic cardiovascular disease (coronary heart disease and stroke), heart failure, and cardiovascular mortality. Although the association of APOs and subsequent CVD has been robustly demonstrated, the mechanisms underlying these associations remain incompletely understood. For HDPs, development of chronic hypertension appears to be a key mediator of future CVD. Numerous other hypotheses have been proposed, including shared genetic predisposition between APOs and CVD, endothelial dysfunction, adverse cardiac remodeling, heightened systemic inflammation, and dysregulated cellular senescence. Potential interventions to mitigate the subsequent development of CVD after an APO include lifestyle interventions, pharmacotherapy, and lactation; observational evidence supports protective effects of standard heart-healthy behaviors, and targeted interventions specific to the postpartum population require further development and evaluation. Ensuring transition of care to longitudinal clinicians for ongoing education and monitoring and management of cardiovascular risk factors may be particularly important in women with APOs to decrease subsequent cardiovascular disease risk. Although there is clear evidence of significant racial and socioeconomic disparities in APOs, whether the association of APOs with subsequent CVD differs by race/ethnicity is less clear and requires further research.

Glycerol was used as a substrate in the bio-production of poly(hydroxyalkanoates) (PHAs) in an effort to establish an alternative outlet for glycerol and produce value-added products. Pseudomonas oleovorans NRRL B-14682 and Pseudomonas corrugata 388 grew and synthesized poly(3-hydroxybutyrate) (P3HB) and medium-chain-length PHA (mcl-PHA) consisting primarily of 3-hydroxydecanoic acid (C(10:0); 44 +/- 2 mol %) and 3-hydroxydodecenoic acid (C(12:1); 31 +/- 2 mol %), respectively, from glycerol at concentrations up to 5% (v/v). Cellular productivity maximized at 40% for P. oleovorans in 5% (v/v) glycerol and 20% for P. corrugata in 2% (v/v) glycerol after 72 h. Increasing the glycerol media concentration from 1% to 5% (v/v) caused a 61% and 72% reduction in the molar mass (M(n)) of the P3HB and mcl-PHA polymers, respectively. Proton-NMR analysis of the glycerol-derived P3HB revealed that the M(n) decrease was the result of esterification of glycerol onto the polymer in a chain terminating position. However, no evidence of glycerol-based chain termination was present in the mcl-PHA. The growth patterns of P. oleovorans and P. corrugata on glycerol permitted their use as mixed cultures to produce natural blends of P3HB and mcl-PHA. By incorporating a staggered inoculation pattern and varying the duration of the fermentations, P3HB/mcl-PHA ratios were achieved that varied from 34:66 to 96:4.

Background: Advancements in medical technology and pharmacologic interventions have drastically improved survival of infants born preterm and low birth weight, but knowledge regarding the long-term health impacts of these individuals is limited and inconsistent.Aim: To investigate whether an individual's birthweight or history of being born preterm increases the risk of an adverse reproductive outcome.Study design: Nested case-control study within the Women's Health Initiative.Subjects: 79,934 individuals who self-reported their personal birthweight category and/or preterm birth status. Outcomes measures: Self-reported pregnancy outcomes: subfertility, miscarriage, stillbirth, preeclampsia, gestational diabetes, gestational hypertension, preterm birth, low birthweight infant, high birthweight infant. Logistic regression models were used to estimate unadjusted and adjusted odds ratios (OR).Results: After adjustments, individuals reporting their birthweight <6lbs. were 20 % more likely to have a stillbirth or 70 % more likely to have a low birthweight infant and were less likely to have a full-term birth or high birthweight infant during their pregnancy. Individuals reporting a birthweight =10 lbs. were more likely to have a high birthweight infant (OR 3.49, 95 % CI 2.73-4.39) and less likely to have a low birthweight infant (OR 0.64, 95 % CI 0.47-0.82). Individuals born preterm were at increased risk for infertility, miscarriage, preeclampsia, gestational diabetes, and delivering a preterm or low birthweight infant.Conclusions: As more individuals born preterm and/or low birthweight survive to adulthood, the incidence and prevalence of poor reproductive outcomes may increase. Women born at extremes of birthweight and prematurity may need to be monitored more closely during their own pregnancies.