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BackgroundDespite increasing evidence of a common link between bone and heart health, the relationship between bone mineral density (BMD) and heart failure (HF) risk remains insufficiently studied.Methods and ResultsWe investigated whether BMD measured by dual‐energy x‐ray absorptiometry was associated with incident HF in an older cohort. Cox models were stratified by sex and interactions of BMD with race assessed. BMD was examined at the total hip and femoral neck separately, both continuously and by World Health Organization categories. Of 1250 participants, 442 (55% women) developed HF during the median follow‐up of 10.5 years. In both black and nonblack women, neither total hip nor femoral neck BMD was significantly associated with HF; there was no significant interaction by race. In black and nonblack men, total hip, but not femoral neck, BMD was significantly associated with HF, with evidence of an interaction by race. In nonblack men, lower total hip BMD was associated with higher HF risk (hazard ratio, 1.13 [95% CI, 1.01–1.26] per 0.1 g/cm2 decrement), whereas in black men, lower total hip BMD was associated with lower HF risk (hazard ratio, 0.74 [95% CI, 0.59–0.94]). There were no black men with total hip osteoporosis. Among nonblack men, total hip osteoporosis was associated with higher HF risk (hazard ratio, 2.83 [95% CI, 1.39–5.74]) compared with normal BMD.ConclusionsAmong older adults, lower total hip BMD was associated with higher HF risk in nonblack men but lower risk in black men, with no evidence of an association in women. Further research is needed to replicate these findings and to study potential underlying pathways.

BACKGROUND Warfarin is effective in preventing stroke and systemic embolism in atrial fibrillation (AF) but has several limitations. The new oral anticoagulants (NOACs) address many of these limitations but their impact on prescribing practices in older adults with AF is unknown. DESIGN Retrospective observational cohort study SETTING Academic medical center in St. Louis, MO, USA PARTICIPANTS Patients age ≥75 with AF admitted from October 2010 through September 2015 (N=6568, 50% female, 15% non-white). MEASUREMENTS NOACs and warfarin prescribed at discharge were obtained from hospital discharge summaries. Linear regression was used to examine quarterly trends in use of these agents. Multivariable logistic regression was used to assess independent predictors of anticoagulant use. RESULTS NOAC use increased over time (correlation coefficient [r]=0.87, p<0.001), warfarin use did not change (r=−0.16, p=0.500), and overall anticoagulant use (NOACs and warfarin) increased (r=0.68, p=0.001). NOAC use increased over time in all age groups (ages 75–79, 80–84, 85–89) except age ≥90, but the rate of NOAC uptake was attenuated by increasing age. There was no consistent relationship between age and warfarin or overall anticoagulant use, except patients age ≥90 had consistently lower use. Overall, <45% of patients were prescribed an anticoagulant. In multivariable analysis, younger age, white race, female gender, higher hemoglobin, higher creatinine clearance, being on a medical service, hypertension, stroke/TIA, no history of intracranial hemorrhage and modified HAS-BLED score <3 increased the likelihood of receiving NOACs. CONCLUSION Prescription of anticoagulants for AF increased in older adults primarily due to an increase in the use of NOACs. Nonetheless, less than 45% of patients were prescribed an anticoagulant. Additional research is needed to optimize prescribing practices for older adults with AF.

Atrial fibrillation (AF) is a highly prevalent arrhythmia associated with a fivefold increase in the risk of stroke. However, this risk is not homogeneous and varies considerably depending on the presence of several demographic and clinical factors. Independent risk factors for stroke in patients with AF include age ≥65 years, female sex, congestive heart failure, prior stroke or transient ischemic attack, hypertension, diabetes mellitus and vascular disease. Based on these indicators, risk stratification schemes to identify patients at low-, moderate-, and high-risk for stroke have been developed and validated. The CHADS2and CHA2DS2-VASc schemes are widely used and have good predictive accuracy for stroke. Current guidelines recommend the CHA2DS2-VASc scheme, in part because it more accurately identifies patients at truly low risk for stroke who do not require antithrombotic therapy. This article provides an overview of risk factors for stroke in patients with AF, including discussion of the CHADS2and CHA2DS2-VASc schemes.

Ramsay Hunt Syndrome (RHS) is a rare complication of latent varicella-zoster virus (VZV) infection that can occur in immunocompetent host. It usually involves ipsilateral facial paralysis, ear pain and facial vesicles. Disseminated herpes zoster is another complication of VZV infection typically seen in immunocompromised hosts. We describe a patient with relapsed chronic lymphocytic leukemia (CLL) who presented simultaneously with RHS and disseminated herpes zoster. While other complications have been documented to coexist with RHS, to our knowledge, this is the first reported case in the literature of concurrent RHS with disseminated herpes zoster.

BACKGROUND Blacks have a lower risk of AF despite having more AF risk factors, but the mechanism remains unknown. PAC burden is a recently identified risk factor for AF. OBJECTIVES To determine whether the burden of premature atrial contractions (PACs) explains racial differences in atrial fibrillation (AF) risk. METHODS PAC burden (number per hour) was assessed by 24-hour ambulatory ECG monitoring in a randomly selected subset of Cardiovascular Health Study participants. Participants were followed prospectively for the development of AF, diagnosed by study ECG and hospital admission records. RESULTS Among 938 participants (median age 73 years, 34% Black, 58% female), 206 (22%) developed AF over a median follow-up of 11.0 years (IQR 6.1 to 13.4). After adjusting for age, sex, body mass index, coronary disease, congestive heart failure, diabetes, hypertension, alcohol consumption, smoking status, and study site, Black race was associated with a 42% lower risk of AF (HR 0.58, 95% CI 0.40 to 0.85, p=0.005). The baseline PAC burden was 2.10 times (95% CI 1.57 to 2.83, p<0.001) higher in Whites than Blacks. There was no detectable difference in PVC burden by race. PAC burden mediated 19.5% (95% CI 6.3 to 52.5) of the adjusted association between race and AF. CONCLUSIONS On average, Whites exhibited more PACs than Blacks, and this difference statistically explains a modest proportion of the differential risk of AF by race. The differential PAC burden, without differences in PVCs, by race suggests that identifiable common exposures or genetic influences might be important to atrial pathophysiology.

Background: Previous studies have suggested an association between bone mineral density (BMD) and heart failure (HF) risk that may be racedependent. Methods:We evaluated the relationship between BMD and incident HF in a cohort of older adults, the Health, Aging, and Body Composition (Health ABC) study (n = 2835), and next performed a pooled analysis involving a second older cohort, the Cardiovascular Health Study (n = 1268). Hip BMD was measured by dual-energy X-ray absorptiometry in both cohorts and spine BMD by computed tomography in a subset from Health ABC.Results: In Health ABC, lower BMD at the total hip was associated with higher incident HF in Black women after multivariable adjustment. Similar associations were found for BMD at the femoral neck and spine. In both cohorts, pooled analysis again revealed an association between lower total hip BMD and increased risk of HF in Black women (HR = 1.41 per 0.1-g/cm 2 decrement [95% CI = 1.23-1.62]), and showed the same to be true for White men (HR = 1.12 [1.03-1.21]). There was a decreased risk of HF in Black men Abbreviations: BMD, bone mineral density; CHD, coronary heart disease; CT, computed tomography; DXA, dual-energy X-ray absorptiometry; eGFR, estimated glomerular filtration rate; FEV 1 , forced expiratory volume in 1 s; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction.

Introduction: Despite normal ejection fraction, nonobstructive hypertrophic cardiomyopathy (nHCM; rest and provoked gradients <30 mmHg) is associated with high rates of angina, arrhythmias and heart failure symptoms, as well as abnormalities of echo-based myocardial strain. Using Myocardial Work (MW) analysis, we investigated the potential mechanisms contributing to exercise-induced symptoms in nHCM. Methods and Results: Using validated methods (EchoPAC), longitudinal strain and non-invasive blood pressure were integrated to generate normalized left ventricular pressure curves and pressure-strain loops to derive global and segmental MW data in 14 nHCM patients with normal ejection fraction (>55%) who underwent treadmill stress testing. Global myocardial work efficiency was expressed as the ratio of global constructive work over the sum of global constructive and wasted work. A total of 9 of 14 patients reported symptoms during exercise (chest pain, dyspnea, and palpitations) and this group had reduced global myocardial work efficiency compared to those without exercise-induced symptoms (85% vs 90%, respectively, p = 0.04, Figure 1). No statistical differences were noted in age, % men, maximal wall thickness, ejection fraction, E/e’ ratio, resting blood pressure, resting global strain and exercise performance between symptomatic and asymptomatic patients. Conclusions: Despite similar ventricular morphology, resting mechanics and exercise performance, nHCM patients with symptoms during exercise have worse myocardial work efficiency. Our data suggest that mechanisms potentially impacting global strain may be distinct from those affecting myocardial work efficiency. Understanding these differences may offer insights into management of exercise-induced symptoms.