AUC Officers 2014-15 President Jeffrey R. Bender, M.D. Yale University School of Medicine Vice President C. Noel-Bairey-Merz M.D. Cedars-Sinai Medical Center Secretary-Treasurer Ivor J. Benjamin, M.D. The Medical College of Wisconsin Councilors Emelia J. Benjamin, M.D. Boston University School of Medicine Anne Curtis, M.D. Buffalo General Hospital Kim A. Eagle, M.D. University of Michigan Health System Robert Simari, M.D. University of Kansas School of Medicine PROGRAM AND ABSTRACTS Association of University Cardiologists Fifty-Fourth Annual Meeting Carmel Valley Ranch Carmel, California January 21– 23, 2015 2015 2015 AUC Annual Meeting Program Thursday, January 22, 2015, cont. Wednesday, January 21, 2015 2:00 PM – 5:00 PM 3:00 PM – 5:00 PM 6:00 PM – 8:00 PM Council Meeting – Oak Room B Emeritus Forum -Redwood CD New Guidelines for the Prevention of Cardiovascular Disease: Concept & Controversy Sidney C. Smith, Jr., M.D., University of North Carolina Personalizing Medicine: Hype & Current Realty Dan Roden, M.D., Vanderbilt University Reception – Clubhouse Thursday, January 22, 2015 8:00 – 9:00 AM 9:00 AM – 12:00 PM 9:00 – 9:45 1:05 – 1:35 An Evolving Understanding of Patients Presenting with Non-ST Elevation Acute Coronary Syndromes (NSTE ACS) Robert A. Harrington, M.D., Professor of Medicine, Stanford University 1:35 – 2:05 The Natriuretic Peptides and Cardiometabolic Health: From Base Pairs to Bedside Thomas J. Wang, M.D., Professor of Medicine ,Vanderbilt University Medical Center 2:05 – 2:35 Β- Aminoisobutyric Acid is an Exercise Myokine Robert E. Gerszten, M.D., Professor of Medicine, Massachusetts General Hospital 2:35 – 3:05 Moving Cardiovascular Risk Assessment Beyond a Single Biomarker L. Kristin Newby, M.D., Associate Professor of Medicine, Duke University Medical Center 3:05 – 3:20 Break 3:20 – 3:50 The Heart Failure Epidemic: A Contemporary Community Perspective Veronique L. Roger, M.D., MPH Professor of Medicine & Epidemiology, Mayo Clinic College of Medicine 3:50 – 4:20 Passive Myocardial Stiffness in Patients with Heart Failure and a Preserved Ejection Fraction: Contributions of Collagen and Titin Michael R. Zile, M.D., Professor of Medicine, Medical University of South Carolina & Department of Veterans Affairs Medical Center Continental Breakfast – Oak Room The President’s Program - Redwood Room THE 29th GEORGE BURCH MEMORIAL LECTURE Genes, Genomes and the Future of Medicine Richard Lifton, M.D., Yale University School of Medicine 9:45 – 10:30 FEATURED LECTURE Cholesterol: A Guide for the Perplexed Harlan Krumholz, M.D., Yale University School of Medicine 10:30 – 11:00 Break – Oak Room 11:00 – 11:45 PRESIDENT’S LECTURE Integrin-induced Effects on RNA Stability in Angiogenesis and Neuroinflammation Jeffrey Bender, M.D., Yale University School of Medicine 11:45 – 12:00 Discussion 12:00 – 1:00 Lunch – Oak Room 1:00 – 5:00 First Scientific Session – Redwood Room 1:00 – 1:05 2015 AUC Annual Meeting Program Introduction of New Members in Attendance: Keith Ferdinand Robert Gerszten Linda Gillam Robert Harrington L. Kristin Newby Rita Redberg Veronique Roger Thomas Wang 2015 AUC Annual Meeting Program 2015 AUC Annual Meeting Program Thursday, January 22, 2015, cont. 4:20-4:50 4:50 PM 7:00 PM – 11:00 PM 10:00 – 10:30 Break Cardiac Transplantation in Foreclosure Lynne W. Stevenson, M.D., Professor of Medicine, Brigham & Women’s Hospital 10:30 – 11:00 The Blood Pressure Effects of New Antidiabetic Drugs Keith Ferdinand, M.D., Professor of Clinical Medicine, Tulane University School of Medicine Adjourn for the day 11:00 – 11:30 Cardiovascular Disease and Diabetes as Cause of Death in a Semirural Black/White Population: The Bogalusa Heart Study Gerald S. Berenson, M.D., Emeritus Boyd Professor Tulane University Health Sciences Center 11:30 – 12:00 Discordance Between Methods for Assessment of Mitral Regurgitation Severity: What Can Ventricular Remodeling Tell Us? Linda Gillam, M.D., Professor of Medicine, Atlantic Health System RECEPTION AND DINNER (BLACK TIE) 7:00 – 8: 00 Reception - Oak Room 8:00 – 11:00 Dinner – Redwood Room Friday, January 23, 2015 7:30 AM – 8:00 AM Continental Breakfast – Oak Room 8:00 AM – 9:00 AM Business Meeting – Redwood Room Memorial Minutes Election of New Members Election of Officers Other New Business 9:00 AM – 12:00 PM Second Scientific Session – Redwood Room 9:00 – 9:30 Selective Reporting of High-Risk Cardiovascular Device Trials Rita F. Redberg, M.D., Professor of Medicine, University of California San Francisco Medical Center 9:30 – 10:00 Estimating Sympathetic Tone by Recording Subcutaneous Nerve Activity in Ambulatory Dogs Peng-Sheng Chen, M.D., Ph.D., Chair of Cardiology, The Krannert Institute of Cardiology Adjourn 2015 AUC Annual Meeting ABSTRACTS An Evolving Understanding of Patients Presenting with Non-ST Elevation Acute Coronary Syndromes (NSTE ACS) 2015 AUC Annual Meeting ABSTRACTS The Natriuretic Peptides and Cardiometabolic Health: From Base Pairs to Bedside Robert A. Harrington, MD, Stanford University, Stanford, CA Thomas J. Wang, MD, Vanderbilt University Medical Center The acute coronary syndromes (ACS) remain a major public health problem with more than 2 million hospital admissions for patients presenting with NSTE ACS annually around the globe, including more than 1.2 million in the United States. Much progress has been made in our understanding of these patients presenting with ACS over the last twenty-five years. A critical piece of this knowledge advance has been the formation and ongoing continuation of global academic collaborations as a unifying force to drive the science, the clinical trials and the clinical practice guidelines. Advances in the management of these patients has been accompanied by a change in the disease terminology, moving from the static, and retrospective diagnoses of unstable angina and non-q-wave infarction to the dynamic diagnosis of ACS. The heart serves a major endocrine function by producing a family of hormones known as the natriuretic peptides (NPs). The classical actions of the NPs are natriuresis,diuresis, and vasodilation. In the past decade, a large body of experimental evidence has emerged that the NPs have metabolic actions as well, including lipolysis, activation of brown fat, and enhanced thermogenesis. Collectively, these data suggest that the NP axis could play a key role in modulating susceptibility to cardiometabolic risk. Genetic and environmental factors influence the heart’s ability to produce NPs at rest and with stress (for instance, with salt loading). For instance, obese individuals have 20-40% lower circulating NPs than lean individuals, despite having greater degrees of RAAS activation, increased plasma volume, and hypertension (factors that should trigger NP release). Reduced cardiac synthesis of NPs is observed in murine models of weight gain and obesity, and may be mediated in part by altered insulin signaling. Genetic data support the hypothesis that reduced NP production can interfere with salt homeostasis and fat metabolism. Mice with NP deficiency have hypertension, ventricular hypertrophy, and glucose intolerance. In humans, approximately 40% of the inter-individual variability in circulating ANP and BNP is attributable to additive genetic factors. A variant in the 3’ UTR of the NPPA gene (rs5068) is associated with 50% higher levels of ANP in individuals on standardized diets, and a 10-15% lower long-term risk of hypertension. We have shown that this effect is mediated by a cardiac-expressed microRNA (miR-425) that modulates ANP production in an allele-specific manner, with the minor allele conferring resistance to downregulation by miR-425. These findings illustrate a novel mechanism for salt homeostasis involving a microRNA. Given the tendency for obesity to inhibit NP production, obese persons could be caught in a “vicious cycle,” whereby a suppressed NP system impairs the ability to resist fat accumulation. Weight loss or intensive lifestyle modification can, at least partially, reverse the low NP levels. Pharmacologic interventions offer additional possibilities. For instance, preliminary data suggest that augmenting cGMP with phosphodiesterase-5 inhibitors may have favorable metabolic effects. Other agents that modulate NP/cGMP signaling, in various phases of development and testing, could lead to novel approaches for the treatment of individuals with cardiometabolic disease. This shift in thinking about the acute presentation has provided some of the impetus for the evolution of antithrombotic therapies, progressing from the use of aspirin and unfractionated heparin to more sophisticated target directed-regiments of both antiplatelets (glycoprotein IIb/IIIa inhibitors, P2Y12 inhibitors) and anticoagulants (low molecular weight heparins, direct thrombin inhibitors, factor Xa inhibitors). Critical insights into the optimal balance of ischemic protection while reducing bleeding risk have been important, and ongoing, areas of clinical investigation. Risk stratification initially, and importantly, focused on the 12-lead ECG but has evolved to involve more detailed risk scores that incorporate patient characteristics, the ECG and an increasing list of biomarkers to provide both prognostic and therapeutic guidance at the point-of-care. Understanding how to integrate risk knowledge, antithrombotic therapies and use of coronary angiography/revascularization has been critical to continuing to improve outcomes among this group of patients. While much focus of clinical investigation among the group of patients with NSTE ACS, has been on the period of acute presentation given the heightened early risk of death and other ischemic complications, the long-term follow-up studies has made clear that much work needs to be done in attenuating the accumulating risk over time. 2015 AUC Annual Meeting ABSTRACTS 2015 AUC Annual Meeting ABSTRACTS Β-Aminoisobutyric Acid is an Exercise Myokine Moving Cardiovascular Risk Assessment Beyond a Single Biomarker Lee Roberts, Ponus Bostrom, John O’ Sullivan, Robert Schinzel, Gregory Lewis, Andre Dejam, Youn-Kyoung Lee, Melinda J. Palma, Sondra Calhoun, Anastasia Georgiadi, Ming-Juei Chen, Vasan Ramachandran, Martin Larson, Claude Bouchard, Tuomo Rankinen, Amanda Souza, Clary Clish, Thomas Wang, Jennifer Estall, Alexander Soukas, Chad Cowan, Bruce Spiegelman, Robert E. Gerszten, Massachusetts General Hospital Exercise is an effective intervention for both the prevention and treatment of obesity and type 2 diabetes. Recent studies suggest that skeletal muscle integrates many of the signals contributing to the salutary effects of exercise. The transcriptional coactivator peroxisome proliferator-activated receptor-gamma co-activator-1 (PGC1) regulates metabolic genes in skeletal muscle, and contributes substantially to the response of muscle to exercise. Muscle specific PGC-1 transgenic expression and exercise both increase the expression of thermogenic genes within white adipose. How the PGC-1 mediated response to exercise in muscle conveys signals to other tissues remains incompletely defined. We employed a metabolic profiling approach to examine metabolites secreted from myocytes with forced expression of PGC-1, and identified β-aminoisobutyric acid (BAIBA) as a novel small molecule myokine. BAIBA increases the expression of brown adipocyte-specific genes in white adipose tissue and fatty acid β-oxidation in hepatocytes both in vitro and in vivo through a PPARα mediated mechanism, induces a brown adipose-like phenotype in human pluripotent stem cells, and improves glucose homeostasis in mice. In humans, plasma BAIBA concentrations are increased with exercise and inversely associated with metabolic risk factors in population based cohorts such as the Framingham Heart Study. BAIBA may thus contribute to exercise-induced protection from metabolic diseases. L. Kristen Newby, MD, MHS, Duke University Medical Center Hundreds of reports of protein biomarker associations with cardiovascular outcomes appear in the peer reviewed literature each year, but often in isolation of other putative biomarkers and with limited consideration of clinical predictors of outcome. As a first step to understanding the relative importance of the biomarkers in published observations, we assayed 53 of these putative protein biomarkers that had at least modest literature-reported association with outcomes (HR >1.50) in 550 individuals with suspected coronary disease in the MURDOCK Horizon 1 Cardiovascular Disease Study. Using a modern statistical approach (penalized regression using the Elastic Net) to perform coefficient estimation and variable selection simultaneously across potentially collinear variables (proteins sharing the same biological “pathway”) as well as unrelated biomarkers and detailed clinical characterization, we generated smaller panels of biomarkers that were independently associated with outcomes. For example, this method identified a set of 6 biomarkers (ICAM-1, MMP-3, NT-proBNP, IL-6, sCD40L, and IGFBP2) and 5 clinical variables (age, red-cell distribution width, diabetes mellitus, hemoglobin, and New York Heart Association class) that were strongly associated with death or myocardial infarction during a median 2.5 years of follow up. While this reflects an important step forward, these methods and results only scratch the surface of what is needed and soon may be possible to bring the promise of “stratified medicine” to fruition. Although genetic, protein, metabolite, and transcriptomic biomarkers have been associated with cardiovascular risk, their contributions that may reflect multiple intersecting pathways or read outs on the same pathway may not be considered in the context of systems biology, and most frequently assessment of disease state and risk is static, failing to incorporate the influence of temporal changes in biology or the interactions of the macro- and micro-environment or individual behavior with biology over time. Longitudinal population registries and biorepositories, advances in molecular platform technology, and access to electronic health records combined with evolution in computing, informatics, and statistical capabilities promise to enable temporal characterization of health and disease not only by gross phenotypic observation but according to underlying molecular mechanism and influence of social determinants, and in turn enable development of targeted therapeutic interventions and disease prevention strategies at the individual and population levels. 2015 AUC Annual Meeting ABSTRACTS The Heart Failure Epidemic: A Contemporary Community Perspective 2015 AUC Annual Meeting ABSTRACTS Passive Myocardial Stiffness in Patients with Heart Failure and a Preserved Ejection Fraction: Contributions of Collagen and Titin Veronique L. Roger, MD,MPH, Mayo Clinic College of Medicine Designated at the turn of the century as a new epidemic of cardiovascular disease, heart failure (HF) constitutes a staggering clinical and public health problem, associated with significant mortality, morbidity, and healthcare expenditures, particularly problematic in an aging population. Epidemiologic data indicate that the incidence of HF has in fact remained stable over the past two decades and that the burden of HF is related to recurrent hospitalizations among a growing number of persons living with HF. HF symptoms reflect is a heterogeneous clinical syndrome, which can present with preserved or reduced ejection fraction. The case mix of HF has changed markedly over time with a growing proportion of cases presenting with preserved ejection fraction. It is increasingly recognized that HF with preserved ejection fraction is itself a heterogeneous condition and its mechanistic underpinnings have yet to be fully delineated. Indeed, numerous factors have been envisioned involving the heart and other organs and a complex cross talk with coexisting chronic conditions. Importantly, there is no specific treatment for HF with preserved EF and its outcomes, death and hospitalizations, are similar to those of HF with reduced EF. While important progress has been made in improving the survival of patients living with HF, hospitalizations remain frequent and a substantial number of hospitalizations are not related to HF. To prevent hospitalizations, a comprehensive characterization of their determinants is imperative and must integrate the impact of multimorbidity related to coexisting conditions. New models of patient-centered care that draw on community-based resources to support HF patients with complex coexisting conditions hold the promise to alter the course of the burden of hospitalizations in HF. Michael R. Zile, MD, C. Baicu, J. Ikonomidis, R. Stroud, P. Nietert, A. Bradshaw, R. Slater, B. Palmer, P. Van Buren, M. Meyer, M. Redfield, D. Bull, H. Granzier, M. LeWinter, Medical University of South Carolina Medical University of South Carolina & Department of Veterans Affairs Medical Center, Charleston, SC, University of Arizona, Tucson, AZ, University of Vermont, Burlington, VT, Mayo Clinic, Rochester, MN, University of Utah Health Sciences Center, Salt Lake City, UT. Background: The purpose of this study was to determine whether patients with heart failure and a preserved ejection fraction (HFpEF) have an increase in passive myocardial stiffness and the extent to which discovered changes are dependent on changes in extracellular matrix fibrillar collagen and/or cardiomyocyte titin. Methods and Results: Seventy patients undergoing coronary artery bypass grafting underwent an echocardiogram, plasma biomarker determination, and intraoperative left ventricular (LV) epicardial anterior wall biopsy. Patients were divided into 3 groups: referent control (n=17, no hypertension or diabetes), hypertension (HTN) without(-) HFpEF (n=31), and HTN with (+)HFpEF (n=22). One or more of the following studies were performed on the biopsies: passive stiffness measurements to determine total, collagen-dependent and titin-dependent stiffness (differential extraction assay), collagen assays (biochemistry or histology), or titin isoform and phosphorylation assays. Compared with controls, patients with HTN(-)HFpEF had no change in LV end diastolic pressure (LVEDP), myocardial passive stiffness, collagen, or titin phosphorylation but had an increase in biomarkers of inflammation (CRP, sST2, TIMP-1). Compared with both control and HTN(-)HFpEF, patients with HTN(+)HFpEF had increased LVEDP, left atrial volume, NT-proBNP, total, collagen-dependent and titin-dependent stiffness, insoluble collagen, increased titin phosphorylation on PEVK S26, reduced phosphorylation on N2B S469, and increased biomarkers of inflammation. Conclusions: Hypertension in the absence of HFpEF, did not alter passive myocardial stiffness. Patients with HTN(+)HFpEF had a significant increase in passive myocardial stiffness; collagen-dependent and titin-dependent stiffness were increased. These data suggest that the development of HFpEF is dependent on changes in both collagen and titin homeostasis. 2015 AUC Annual Meeting ABSTRACTS Cardiac Transplantation in Foreclosure Lynne W. Stevenson, MD, Brigham & Women’s Hospital Current estimates of about 150,000 potentially eligible patients contrast with the donor supply of about 2,200 hearts annually. After listing, the highest of 3 priority levels, Status IA, requires ongoing support with high dose inotropic therapy, extracorporeal support, or a life-threatening complication of an implanted VAD. Although this priority assumed death would otherwise be imminent within a few days, the average waiting time at IA ranges is currently over 6 months in the worst regions. The proportion of recipients supported by VAD prior to transplant is about 40% nationwide, but almost 100% in regions with longer waiting times, where ideal candidates for transplantation must undergo obligatory VAD surgery first, after which over 30% will become ineligible for transplantation. The most troubling ethical aspect of the current lifeboat dilemma is the inequity of access; patients with sufficient resources now move across the country with their families for 6-12 months to undergo transplantation with short waiting times in the regions where donor hearts are more plentiful. Focus on risk scores for revision of the priority system diverts attention from the fundamental insolvency of the waiting list. In addition to 4,000 patients already waiting for hearts, about 30% more patients are listed each year than actually undergo transplantation. While laudable efforts continue to encourage organ donation and improve donor preservation, the most consistent response to the donor- recipient disparity is to take greater risks with marginal donors. Regardless of these efforts, we cannot continue to make more promises than we can keep. The list must return to an equilibrium at which the number of added patients matches the number of patients removed. If we reduced new listings by 20-25%, within 5 years the list could reach a steady state at less than 1,000, and a majority of patients listed would be again able to undergo transplantation within a year. It would not be necessary for patients to undergo additional surgery for ventricular assist devices except when needed urgently to sustain organ function and the success of transplantation. How could the list be trimmed? Many contraindications for transplantation have been stretched since approval for reimbursement in 1984, such as diabetes, renal dysfunction, substance abuse or non-compliance, obesity and advanced age. Regardless of which criteria are selected for revision, it will be necessary to reach national consensus. Like disarmament, constraint will not be effective if optional, as patients will shop among centers for a favorable decision. The transplant community bears responsibility for failing to support both realistic expectations and a robust portfolio of alternative care programs when neither transplantation nor mechanical support are good options. There have always been many more people rejected for transplantation than accepted. It is vital that the medical community align to say "no" to a few more in order to ensure that all available hearts are distributed equitably and ethically for the greatest benefit. 2015 AUC Annual Meeting ABSTRACTS Selective Reporting of High-Risk Cardiovascular Device Trials Chang L, Dhruva S, Chu J, Bero L, and Redberg RF. Objective: To compare clinical trial characteristics and safety and effectiveness results reported in FDA documents for recently approved high-risk cardiovascular devices with the trial characteristics and results reported in peer-reviewed publications. Design and Setting: A search of the publicly available FDA database was performed for all cardiovascular devices receiving premarket approval between Jan 1, 2000 and December 31, 2010. For each study listed in the premarket approval documents, a Medline search was conducted to obtain the corresponding publication. Main Outcome Measures: Clinical trial characteristics, primary endpoints, and safety and efficacy results were compared between the FDA documents and their corresponding publications. Results: There were 106 cardiovascular devices that received premarket approval between January 1, 2000 and December 31, 2010. FDA premarket approval documents for these devices contained a total of 177 studies of which 86 (49%) were published as of January 1, 2013. The mean time from FDA approval to publication was 6.5 months (range -4.8 to 7.5 years). Enrollment number differed for 22 (26%) of the studies compared. Of 152 primary endpoints identified in the FDA documents, three (2%) were labeled as secondary, 43 (28%) were unlabeled, and 15 (10%) were not found in the corresponding publications. Among the primary results, 69 (45%) were identical, 35 (23%) were similar, 17 (11%) were substantially different, and 31 (20%) could not be compared. Conclusions: Many clinical trials for FDA-approved high-risk cardiovascular devices remain unpublished. Even when published, the study population, primary endpoints, and results can differ substantially from data submitted to the FDA. 2015 AUC Annual Meeting ABSTRACTS Estimating Sympathetic Tone by Recording Subcutaneous Nerve Activity in Ambulatory Dogs Peng-Sheng Chen, MD, The Krannert Institute of Cardiology and Division of Cardiology, Department of Medicine, Indiana University School of Medicine Background. The skin of the canine upper thorax is extensively innervated by sympathetic nerves from the stellate ganglion. We hypothesize that it is possible to record sympathetic nerve activity from the subcutaneous tissues of the skin, and that the subcutaneous nerve activity (SCNA) can be used to estimate the stellate ganglion nerve activity (SGNA). Methods and Results: In the first study, we implanted radiotransmitters in normal ambulatory dogs to record left SGNA, left thoracic vagal nerve activity (VNA) and left thoracic SCNA. There was a significant positive correlation between integrated SGNA (iSGNA) and integrated SCNA (iSCNA) in 7 ambulatory dogs, with correlation coefficient of 0.70 (95% confidence interval, CI, 0.61 to 0.84, p < 0.05 for each dog). Tachycardia episodes (heart rate exceeding 150 bpm for ≥ 3 s), were invariably preceded by SGNA and SCNA. There was circadian variation of both SCNA and SGNA. Video monitoring in additional 3 dogs showed that movement was not a cause of high frequency SCNA. The right SGNA correlated strongly with right SCNA and heart rate in 2 anesthetized dogs after apamin injection into the right stellate ganglion. In a second study, we implanted radio transmitters to continuously monitor left stellate ganglion and subcutaneous electrical activities in 7 ambulatory dogs with myocardial infarction, complete heart block and nerve growth factor infusion to the left stellate ganglion. SCNA preceded a ventricular tachycardia (VT), ventricular fibrillation (VF), frequent bigeminy or couplets and premature ventricular contractions within 15 s in 70%, 59% and 61% of arrhythmias, respectively. Similar incidence of 75%, 69% and 62% was noted for SGNA. The Pearson’s correlation coefficient for integrated SCNA and SGNA was 0.73±0.18 (p<0.0001 for all dogs, n=5). Both SCNA and SGNA exhibited circadian variation. Conclusions: SCNA recorded by bipolar subcutaneous electrodes can be used to estimate the sympathetic tone and predict susceptibility to VT and VF in a canine model of ventricular arrhythmia and sudden cardiac death. 2015 AUC Annual Meeting ABSTRACTS The Blood Pressure Effects of New Antidiabetic Drugs Keith Ferdinand MD, Professor of Clinical Medicine, Tulane University School of Medicine More than 70% persons with diabetes mellitus(DM ) have hypertension (HTN) or take antihypertensive medications; and coexisting HTN and DM is associated with: , doubling stroke or cardiovascular (CV) disease risk 5- to 6-fold X risk for end stage ), renal disease(ESRD increased peripheral vascular disease and lower extremity amputations and retinopathy The mechanism(s) of action and associated blood pressure (BP) effects of new antidiabetic drugs, sodium glucose co-transporter (SGLT) inhibitors and glucagon-like peptide–1 (GLP-1) agonists, are described. The SGLT2 inhibitors, the newest antidiabetic medication class approved, block the reabsorption of glucose in the kidney; the chronic osmotic diuresis may reduce BP. There are reductions in clinic SBP up to 5mmHg described in trials with dapagliflozin and canagliflozin. A new study will use the better technique of ambulatory blood pressure monitor (ABPM) to study the effects of empagliflozin, the most recently approved agent, in African Americans, who have a higher risk for DM, HTN and CV disease. Assessment of both glucose and BP lowering effects of empagliflozin in hypertensive African American patients with type 2 DM could provide clinically highly relevant, new information for the use of empagliflozin. The injectable GLP-1 agonists lower glucose by direct interaction with GLP-1 receptors on specific tissues and may lower BP. A recent large, randomized, placebo-controlled, international trial (N=755), with ambulatory blood pressure monitor (ABPM) has been published. The once-weekly GLP-1 receptor agonist, dulaglutide doses (0.75 mg and 1.5mg) shown to be noninferior to placebo on mean 24-hr SBP and DBP. Moreover, dulaglutide 1.5 mg shown to significantly reduce mean 24-hour SBP approximately 2 to 3 mm Hg. The clinical significance of the reduction in SBP and small HR increase with dulaglutide is not known. The potential mechanism(s) of action and outcome significance of these BP/HR effects findings are not known. 2015 AUC Annual Meeting ABSTRACTS Cardiovascular Disease and Diabetes as Cause of Death in a Semirural Black/White Population: The Bogalusa Heart Study Gerald S. Berenson, MD, Sathanur R. Srinivasan, PhD, Rupert Barshop, MPH, Camilio Fernandez, MD, MSC; Ji-Hua Xu, MD; Wei Chen, MD, PhD. Tulane University Health Sciences Center, New Orleans, LA Tulane University Health Sciences Center. New Orleans, LA The Bogalusa Heart Study (BHS) has been ongoing over the past 4 decades. Its primary mission and most critical observation is that cardiovascular (CV) diseases, hypertension and diabetes are the major causes of death with evidences of risk factors related to these causes begin in childhood. Some 566 deaths have now occurred from all causes, including: traumatic, motor vehicle accidents, homicides and suicides. Cardiovascular events as an apparent cause begin to appear in the 4th decade of life. Some 156 have cardiac events and 40 cases have died from myocardial infarction based on local obituaries, coroner records and death certificates and personal information by BHS staff. Comparative risk factor data from their last observation and in those with myocardial infarction, 4 to 35 years ago to earlier levels in childhood show differences from the overall general population. Trends of risk factor differences are noted but because of small numbers of subjects with MI the childhood values for prediction are not statistically significant. The average age of death from MI is shown in the attached table. It is apparent that deaths from CV disease and type II diabetes mellitus are prominent and occur at a young age. These observations provide a reason to begin primordial prevention in early life. 2015 AUC Annual Meeting ABSTRACTS Discordance Between Methods for Assessment of Mitral Regurgitation Severity: What Can Ventricular Remodeling Tell Us? Linda Gillam, MD, Atlantic Health System Background: Recent guidelines supporting prophylactic surgery in asymptomatic patients with primary mitral regurgitation (MR) who are free of left ventricular systolic dysfunction and other triggers for intervention (atrial fibrillation, pulmonary hypertension) mandate an accurate reproducible assessment of MR severity. Since the surgery is associated with risks of death, stroke and the possibility of unsuccessful repair, it is important that intervention be limited to those whose regurgitation is severe. While magnetic resonance imaging (MRI) provides robust methods for assessing valvular regurgitation, the assessment of MR severity is frequently based on echocardiography alone. While the American Society of Echocardiography recommends an integrated approach, its guidelines provide no guidance as to weighting of what may be discordant measures and emphasize parameters that reflect color Doppler jet characteristics assessed at a single point in systole. Prior studies have reported variable agreement between MRI and echocardiographic estimates of MR severity but have been limited by the absence of a reliable independent gold standard, the limitations of angiographic grading being well appreciated. The degree of left ventricular remodeling following mitral valve surgery may provide such a reference standard. Methods: In a series of prospective multicenter studies, MR severity has been assessed using both echocardiography (2D and 3D) and MRI. Echocardiographic methods include vena contracta, PISA determined effective regurgitant orifice area, regurgitant volume, regurgitant fraction, jet area as well as the assessment of pulmonary venous and peak antegrade mitral flow velocities. MRI derived indices are regurgitant volume and regurgitant fraction as well as left ventricular volumes. Clinical variables including symptom status, exercise performance and BNP are also captured. In patients, undergoing isolated mitral valve surgery, an additional MRI is performed 5-7 months following surgery to reassess LV volumes. Primary analyses have focused on the reproducibility of the methods, concordance of echocardiographic and MRI grading of MR and the ability of MR quantitation to predict postsurgical LV remodeling. Initial results (in press): In the initial cohort of 103 pts with MR (82% primary, 18% functional), 38 of whom underwent mitral surgery and 26 of whom had post-surgical MRI, agreement between MRI and integrated 2D echocardiographic estimates of MR severity was modest (r = 0.6, p <0.0001) with poorer correlation in the subset sent for surgery (r = 0.4, p=0.01) and with echo tending to overestimate MR severity as judged by MRI. There was a strong correlation between post surgical LV remodeling and MR severity as assessed by MRI (r = 0.85, p<0.0001), and no correlation between post surgical LV remodeling and MR severity as assessed by 2D echocardiography (r = 0.32, p=0.1). Conclusions: MRI may be superior to 2D echo for the assessment of MR severity and may be important in confirming the presence of severe MR in patients being considered for surgery, particularly in the absence of symptoms. Ongoing studies: Additional studies are underway incorporating clinical outcomes, subgroup analyses based on MR etiology, and evaluating echo-MRI correlation for 3D echo approaches as well as individual 2D echo approaches. AUC Upcoming Meetings UPCOMING MEETINGS January 13-15, 2016 Renaissance Vinoy, St. Petersburg, Florida January 18-20, 2017 Royal Palms Resort & Spa, Phoenix, Arizona
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