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Objectives: Peripheral artery disease (PAD) is associated with decreased physical function and increased mortality in the general population. We previously found that PAD is common in middle-aged women with and without HIV infection, but its association with functional decline is unclear. We examine the contribution of PAD to functional decline in the Women's Interagency HIV Study, controlling for traditional cardiovascular risk factors and HIV-related factors.Methods: Analysis included 1839 participants (72% with HIV) with measured anklebrachial index (ABI) and 4 m gait speed. ABI values categorized PAD severity. Linear models with repeated measures estimated the association of PAD severity with logtransformed gait speed after controlling for demographic, behavioral, and metabolic risk factors, and HIV/hepatitis C virus status.Results: Median age was 50 years and more than 70% were Black. Compared with normal ABI, there was a dose-response relationship between increasing PAD severity and slower gait speed in univariable analyses: 6% slower gait speed for low-normal ABI [95% confidence interval (CI): 4-9%], 10% for borderline PAD (95% CI: 6-13%), 14% for mild PAD (95% CI: 9-18%), and 16% for moderate-severe PAD (95% CI: 5-25%). PAD severity remained associated with slower gait speed in multivariable analyses. HIV/hepatitis C virus co-infection was independently associated with 9% (95% CI: 4-14%) slower gait speed compared with those with neither infection. Among women with HIV, neither CD4 þ cell count nor HIV-RNA level was associated with gait speed. Conclusion:In middle-aged women with and without HIV infection, greater PAD severity is associated with progressively slower gait speed. Early detection of subclinical PAD may decrease the risk of lower extremity functional impairment and its long-term health consequences.

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Carcinoid crisis is a life-threatening manifestation of carcinoid syndrome characterized by profound autonomic instability in the setting of catecholamine release from stress, tumor manipulation, or anesthesia. Here, we present an unusual case of carcinoid crisis leading to acute systolic heart failure requiring mechanical circulatory support. ( Level of Difficulty: Intermediate. )

Introduction: Methamphetamine use and overdose deaths are increasing. People who use methamphetamine are at risk for methamphetamine-associated heart failure (meth-HF). Cardiac fibrosis has been reported in nonischemic cardiomyopathies, but the role of cardiac fibrosis and other factors underlying the pathophysiology and reversibility of meth-HF remain unknown. Methods: Participants with meth-HF were recruited into a prospective cohort at a safety net hospital in San Francisco. Data collection included medical history, clinical outcomes, longitudinal echocardiograms (TTEs), markers of inflammation and fibrosis, and cardiac magnetic resonance imaging (CMR). Outcomes included mortality, changes in LVEF, and hospital readmission. Results: Forty-six participants enrolled: median age 51 years, 83% male, 41% Black, 20% Asian, 33% unstably housed, 76% actively using methamphetamine. Baseline TTEs demonstrated LV dilation (median LVIDd 5.7cm, LVIDs 4.7cm) and severely reduced LV systolic function (LVEF<30% in 62%). After median 9 months follow-up, 13% were deceased. Compared to survivors, baseline LV dimensions were larger (mean LVIDd 6.7 vs 5.5cm, p<0.05; LVIDs 6.1 vs 4.5cm, p<0.05) and LVEF was lower (mean 19% vs 29%, p<0.05) among those who died. At baseline, smaller LV size, higher LVEF, and guideline-directed medical therapy (GDMT) were more common in those with LVEF improvement >10% (Fig). CMRs were often abnormal with late gadolinium enhancement and elevated extracellular volume, but there was no clear association with LV recovery. Conclusions: Despite their young age, the meth-HF population has a high mortality rate and severely reduced LVEF with LV dilation. Smaller LV size, higher LVEF, and GDMT were more common in those with LVEF improvement. These findings suggest that early identification and treatment of heart failure in people who use methamphetamine, along with drug cessation, may be associated with reversibility and improved outcomes.