To assess prevalence rates of subjective and objective reports of two cardiovascular disorders (hypertension and hypercholesterolemia) for the same subset of respondents in a large-scale study. To determine whether and the extent to which the socioeconomic health gradient differed in the subjective and objective reports of the two cardiovascular disorders.
Data from the first wave (2009/2011) of The Irish Longitudinal Study on Ageing were used (n = 4,179). This is a nationally representative study of community-dwelling adults aged 50+ residing in Ireland. Subjective measures were derived from self-reports of doctor-diagnosed hypertension and high cholesterol. Objective measure of hypertension was defined as: systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg and/or on antihypertensive medication. Objective measure of hypercholesterolemia was defined as: total cholesterol ≥5.2 mmol/L and/or on cholesterol-lowering medication. Objective measures of low-density-lipoprotein cholesterol and high-density-lipoprotein cholesterol were also used. Two measures of socioeconomic gradient were employed: education and wealth. Binary and multinomial logistic and linear regression analyses were used. Analyses were adjusted for an extensive battery of covariates, including demographics and measures of physical/behavioural health and health care utilization.
Prevalence of cardiovascular disorders: prevalence of hypertension and hypercholesterolemia was significantly higher when the cardiovascular disorders were measured objectively as compared to self-reports (64% and 72.1% versus 37% and 41.1%, respectively). Socioeconomic gradient in hypertension: the odds of being objectively hypertensive were significantly lower for individuals with tertiary/higher education (OR, 0.74; 95% CI, 0.60-0.92) and in the highest tertile of the wealth distribution (OR, 0.77; 95% CI, 0.62-0.95). In contrast, the associations between socioeconomic status and self-reported hypertension were not statistically significant. Socioeconomic gradient in hypercholesterolemia: wealthier individuals had higher odds of self-reporting elevated cholesterol (OR, 1.28; 95% CI, 1.03-1.58). Associations between socioeconomic status and objectively measured hypercholesterolemia and low-density-lipoprotein cholesterol were not significant. Higher education and, to a lesser extent, greater wealth were associated with higher levels of high-density-lipoprotein cholesterol.
Clear discrepancies in prevalence rates and gradients by socioeconomic status were found between subjective and objective reports of both disorders. This emphasizes the importance of objective measures when collecting population data.
Patients with chronic heart failure (CHF) experience a number of debilitating symptoms, which impact on activities of daily living and result in poor quality of life. Prospective memory, which is defined as memory to carry out future intentions, has not been investigated in this group. However, emerging evidence suggests CHF patients have difficulties with cognitive processes related to prospective memory. Self-care, which partly relies on prospective memory, is essential in symptom management and preventing acute clinical deterioration. This study aims to measure prospective memory in CHF patients, and examine the relationship between prospective memory and CHF self-care.
A comprehensive neuropsychological assessment will be conducted to assess a range of cognitive functions and psychopathology. The primary focus will be an assessment of prospective memory using a well-established behavioral measure; Virtual Week. Thirty CHF patients attending a nurse-led management program will be recruited from three hospital sites in Melbourne, Australia and their self-care behaviors will be assessed using the Self-care Chronic Heart Failure Index (SCHFI), a validated self-report tool. An additional 30 healthy controls, matched on age, gender, and IQ will be recruited from the general community.
This is a group comparison study that will provide an evaluation of the prospective memory abilities of CHF patients. The findings of this research will provide insight into whether prospective memory may be hindering patients’ ability to perform adequate self-care.
Chronic heart failure; Self-care; Cognitive function; Prospective memory
CYP2C19*2 polymorphism is related to metabolizer phenotypes resulting in reduced effectiveness in converting the antiplatelet drug clopidogrel to active drug. An association of the genotype itself with adverse outcomes is discussed. We investigated the prognostic value of carriage of the CYP2C19*2 allele in a high risk group of patients with prevalent coronary heart disease (CHD) at baseline during long-term follow-up under conditions of routine clinical care.
In n=1050 patients with stable CHD at baseline genotyping of CYP2C19 allele *2 (rs4244285; 681G>A) was performed. The Cox-proportional hazards model was employed to investigate the association of CYPC19*2 allele status with cardiovascular disease (CVD) events during eight year follow-up. The analysis was also performed in patients who did not take clopidogrel or ticlopidin.
Only the very few patients homozygous for a loss-of-function variant of CYP2C19, allele *2 (2.6%), had a statistically significantly higher incidence rate for secondary CVD events during long-term follow-up than wild-type carriers (50.8 versus 21.5 per 1000 patients years; rate for heterozygous carries 17.2 per 1000 patient years). The hazard ratio after adjustment for covariates compared to the wild-type carriers was 2.59 (95% confidence interval (CI) 1.27-5.28) and 0.80 (95% CI 0.52-1.23) for homozygous and heterozygous allele carriers, respectively.
In this medium-size group of patients with stable CHD homozygous carriers of the loss-of-function allele CYP2C19*2 were at increased risk for subsequent CVD events during 8 year follow-up independent of other risk factors. As only few patients carried the homozygous loss-of-function variant and we found overall no evidence for improved clinical utility, a benefit of genotyping in this patient population seems unlikely.
The known risk factors for coronary heart disease among people prior suffering an out-of-hospital cardiac arrest with validated myocardial infarction aetiology and their thoughts about what lifestyle means to them after surviving have rarely been described. Therefore the aim of the study was to describe risk factors and lifestyle among survivors.
An explanatory mixed methods design was used. All people registered in the Northern Sweden MONICA myocardial registry between the year 1989 to 2007 who survived out-of-hospital cardiac arrest with validated myocardial infarction aetiology and were alive at the 28th day after the onset of symptoms (n = 71) were included in the quantitative analysis. Thirteen of them participated in interviews conducted in 2011 and analysed via a qualitative manifest content analysis.
About 60% of the people had no history of ischemic heart disease before the out-of-hospital cardiac arrest, but 20% had three cardiovascular risk factors (i.e., hypertension, diabetes mellitus, total cholesterol of more or equal 5 mmol/l or taking lipid lowering medication, and current smoker). Three categories (i.e., significance of lifestyle, modifying the lifestyle to the new life situation and a changed view on life) and seven sub-categories emerged from the qualitative analysis.
For many people out-of-hospital cardiac arrest was the first symptom of coronary heart disease. Interview participants were well informed about their cardiovascular risk factors and the benefits of risk factor treatment. In spite of that, some chose to ignore this knowledge to some extent and preferred to live a “good life”, where risk factor treatment played a minor part. The importance of the support of family members in terms of feeling happy and having fun was highlighted by the interview participants and expressed as being the meaning of lifestyle. Perhaps the person with illness together with health care workers should focus more on the meaningful and joyful things in life and try to adopt healthy behaviours linked to these things.
Chronic heart failure requires a complex treatment regimen on a life-long basis. Therefore, self-care/self-management is an essential part of successful treatment and comprehensive patient education is warranted. However, specific information on program features and educational strategies enhancing treatment success is lacking. This trial aims to evaluate a patient-oriented and theory-based self-management educational group program as compared to usual care education during inpatient cardiac rehabilitation in Germany.
The study is a multicenter cluster randomized controlled trial in four cardiac rehabilitation clinics. Clusters are patient education groups that comprise HF patients recruited within 2 weeks after commencement of inpatient cardiac rehabilitation. Cluster randomization was chosen for pragmatic reasons, i.e. to ensure a sufficient number of eligible patients to build large-enough educational groups and to prevent contamination by interaction of patients from different treatment allocations during rehabilitation. Rehabilitants with chronic systolic heart failure (n = 540) will be consecutively recruited for the study at the beginning of inpatient rehabilitation. Data will be assessed at admission, at discharge and after 6 and 12 months using patient questionnaires. In the intervention condition, patients receive the new patient-oriented self-management educational program, whereas in the control condition, patients receive a short lecture-based educational program (usual care). The primary outcome is patients’ self-reported self-management competence. Secondary outcomes include behavioral determinants and self-management health behavior (symptom monitoring, physical activity, medication adherence), health-related quality of life, and treatment satisfaction. Treatment effects will be evaluated separately for each follow-up time point using multilevel regression analysis, and adjusting for baseline values.
This study evaluates the effectiveness of a comprehensive self-management educational program by a cluster randomized trial within inpatient cardiac rehabilitation in Germany. Furthermore, subgroup-related treatment effects will be explored. Study results will contribute to a better understanding of both the effectiveness and mechanisms of a self-management group program as part of cardiac rehabilitation.
German Clinical Trials Register: DRKS00004841; WHO International Clinical Trials: = DRKS00004841
Chronic heart failure; Patient education; Self-management; Evaluation; Cluster-RCT; Cardiac rehabilitation
The skills of patients on oral anticoagulants are critical for achieving good outcomes with this treatment. Self-management, or the capacity of patients to control their INR level and adjust their treatment, is an effective strategy of treatment. Capacity of patients to self manage is determined by a range of factors. The identification of these factors would improve the design of self management programmes and in turn increase the number of patients able to self-manage. The objective of our study is to identify those factors that determine the ability of patients on oral anticoagulant therapy to achieve self-management of their treatment.
This will be a three year quasi- experimental prospective study with a control group. 333 patients on anticoagulant therapy from five health centres of the Basque Health Service are to be followed up for a period of six months each after the intervention, to assess their ability to self-test and self-manage. The intervention will consist of a patient training programme involving the provision of information and practical training concerning their condition and its treatment, as well as how to use a portable blood coagulation monitoring device and adjust their anticoagulant dose.
The ease-of-use of this technique lead us to believe that self-management is feasible and will represent an innovative advance that should have a substantial impact on the quality of life of this patients and their families as well as on the health care provision systems.
Osakidetza Protocol Record ISCIII-11/02285, Oral anticoagulation and self-management, ClinicalTrials.gov Identifier: NCT01878539
Oral anticoagulants; Self-management; Determinants
Radiofrequency ablation (RFCA) became a treatment of choice in patients with recurrent ventricular tachycardia, ventricular fibrillation, and appropriate interventions of implanted cardioverter-defibrillator (ICD), however, electrical storm (ES) ablation in a pregnant woman has not yet been reported.
We describe a case of a successful rescue ablation of recurrent ES in a 26-year-old Caucasian woman during her first pregnancy (23rd week). The arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) was diagnosed 3 years earlier and several drugs as well as 2 ablations failed to control recurrences of ventricular tachycardia. RFCA was performed on the day of the third electric storm. The use of electroanatomic mapping allowed very low X-ray exposure, and after applications in the right ventricular outflow tract, arrhythmia disappeared. Three months after ablation, a healthy girl was delivered without any complications. During twelve-month follow-up there was no recurrence of ventricular tachycardia or ICD interventions.
This case documents the first successful RFCA during ES due to recurrent unstable ventricular arrhythmias in a patient with ARVD/C in pregnancy. Current guidelines recommend metoprolol, sotalol and intravenous amiodarone for prevention of recurrent ventricular tachycardia in pregnancy, however, RFCA should be considered as a therapeutic option in selected cases. The use of 3D navigating system and near zero X-ray approach is associated with minimal radiation exposure for mother and fetus as well as low risk of procedural complication.
Hypertensive patients (HTs) are usually attended in primary care (PC). We aimed to assess the diagnostic accuracy and cost-benefit ratio of 24-hour ambulatory blood pressure monitoring (ABPM) in all newly diagnosed hypertensive patients (HTs) attended in PC.
In a cross-sectional study ABPM was recorded in all 336 never treated HTs (Office BP ≥140 and/or ≥ 90 mm Hg) that were admitted during 16 months. Since benefits from drug treatment in white-coat hypertension (WCH) remain unproven, a cost benefit estimation of a general use of ABPM (vs absence of ABPM) in HTs was calculated comparing the cost of usual medical assistance of HTs only diagnosed in office with that based both on refraining from drug treatment all subjects identified as WCH and on the reduction by half of the frequency of biochemical exams and doctor visits.
Women were 56%, age 51 ± 14 years and BMI 27 ± 4 Kg/m2. Out of these, 206 were considered as true HTs, daytime ABPM ≥ 135 and/or ≥85 mm Hg and 130 (38,7%) were identified as having white coat hypertension (WCH), daytime ABPM <135/85 mm Hg. Versus HTs, WCH group showed higher percentage of women (68% vs 51%) and lower values of an index composed by the association of cardiovascular risk factors. We estimated that with ABPM total medical expenses can be reduced by 23% (157.500 euros) with a strategy based on ABPM for 1000 patients followed for 2 years.
In PC, the widespread use of ABPM in newly diagnosed HTs increases diagnostic accuracy of hypertension, improves cardiovascular risk stratification, reduces health expenses showing a highly favourable benefit-cost ratio vs a strategy without ABPM.
Hypertension; Ambulatory blood pressure monitoring (ABPM); General practice/Family medicine; White coat hypertension (WCH); Cardiovascular risk factors; ABPM cost-benefit
Acute coronary syndrome (ACS) is highly prevalent in Korea and is the third-leading cause of death in Korea; however, the economic cost of ACS on Korean society has not been investigated. This study examined the economic effect of ACS on the Korean population during the period 2004 to 2009.
The analysis used the cost of illness (COI) framework. Data on direct medical costs, direct non-medical costs, and productivity loss related to ACS morbidity and mortality were included. The Korean National Health Insurance Corporation’s claim database was used to obtain data on annual healthcare utilization and expenditures for the entire South Korean population. By using a data mining technique, we identified healthcare claims with ACS-related disease codes. Costs were estimated by using a macro-costing method.
In 2009, the prevalence of ACS in Korea was 6.4 persons per 1,000 population members and the associated mortality rate was 20.2 persons per 100,000 population members. The total cost of ACS in 2009 was USD 918.2 million. Of the total, direct medical cost was USD 425.3 million, direct non-medical cost was USD 11.4 million, and cost associated with morbidity and mortality was USD 481.5 million.
The results show that the total cost of ACS to the Korean society is high. Early and effective management of ACS is required to reduce ACS-associated mortality and morbidity. We suggest that further research be undertaken to determine ways to reduce the economic effects of ACS and its treatment.
Acute coronary syndrome; Cost of disease; Unstable angina; Myocardial infarction; Ischemic heart disease
Obesity causes severe healthcare problem worldwide leading to numerous diseases, such as cardiovascular diseases and diabetes mellitus. Previous Genome-Wide Association Study (GWAS) identified an association between a single nucleotide polymorphism (SNP) rs7138803, on chromosome 12q13 and obesity in European Caucasians. Since the genetic architecture governing the obesity may vary among different populations, we investigate the variant rs7138803 in Chinese population to find out whether it is associated with obesity.
A population-based cohort association study was carried out using the High Resolution Melt (HRM) method with 1851 participants. The association between rs7138803 genotypes and body mass index (BMI) was modeled with a general linear model, and a case–control study for the association between rs7138803 genotypes and obesity was performed using Pearson’s χ2 test. There was no indication of a deviation from Hardy-Weinberg equilibrium (HWE p value = 0.51) in our sample.
No association was detected between SNP rs7138803 and BMI in our Chinese Han population with a P value of 0.51. SNP rs7138803 was found to be not associated with common forms of obesity after adjusting for age and sex in the Chinese population. SNP rs7138803 was not associated with other obesity related traits, including T2DM, hypertension, lipid profiles, and ischemic stroke.
Our data suggest that the rs7138803 exerts no significant effect on obesity in Chinese Han population. Larger cohorts may be more appropriate to detect an effect of this SNP on common obesity.
FAIM2; Single nucleotide polymorphism; Obesity susceptibility
Inadequate diagnosis and suboptimal control of hypertension is a major driver of cardiovascular morbidity and mortality in Africa. Understanding the levels of awareness, treatment and control of hypertension and the associated factors has important implications for hypertension control efforts.
The PubMed database was searched for original articles related to awareness, treatment and control of hypertension in Africa published between 1993 and 2013. The key search terms were: Africa, awareness, treatment, control, and hypertension. Exploration of bibliographies cited in the identified articles was done to provide further studies. Full texts of the articles were obtained from various internet sources and individual authors. A data extraction sheet was used to collect this information.
Thirty eight studies drawn from 23 African countries from all regions of the continent met the inclusion criteria. The levels of awareness, treatment and control varied widely from country to country. Rural populations had lower levels of awareness than urban areas. North African countries had the highest levels of treatment in the continent. There was generally poor control of hypertension across the region even among subjects that were aware of their status and those that were treated. On the whole, the women had a better control status than the men.
There are low levels of awareness and treatment of hypertension and even lower levels of control. Tailored research is required to uncover specific reasons behind these low levels of awareness and treatment, and especially control, in order to inform policy formulation for the improvement of outcomes of hypertensive patients in Africa.
Hypertension; Awareness; Control; Gender; Associated factors
Ectonucleotidase plays an important role in the regulation of cardiac function by controlling extracellular levels of adenine nucleotides and adenosine. To determine the influence of ischemia-reperfusion injury on ectonucleotidase activity in coronary vascular bed, we compared the metabolic profile of adenine nucleotides during the coronary circulation in pre- and post-ischemic heart.
Langendorff-perfused rat hearts were used to assess the intracoronary metabolism of adenine nucleotides. The effects of ischemia on the adenine nucleotide metabolism were examined after 30 min of ischemia and 30 min of reperfusion. Adenine nucleotide metabolites were measured by high performance liquid chromatography.
ATP, ADP and AMP were rapidly metabolized to adenosine and inosine during the coronary circulation. After ischemia, ectonucleotidase activity of the coronary vascular bed was significantly decreased. In addition, the perfusate from the ischemic heart contained a considerable amount of enzymes degrading ATP, AMP and adenosine. Immunoblot analysis revealed that the perfusate from the ischemic heart dominantly contained ectonucleoside triphosphate diphosphohydrolase 1, and, to a lesser extent, ecto-5’-nucleotidase. The leakage of nucleotide metabolizing enzymes from the coronary vascular bed by ischemia-reperfusion was more remarkable in aged rats, in which post-ischemic cardiac dysfunction was more serious.
Ectonucleotidases were liberated from the coronary vascular bed by ischemia-reperfusion, resulting in an overall decrease in ectonucleotidase activity in the post-ischemic coronary vascular bed. These results suggest that decreased ectonucleotidase activity by ischemia may exacerbate subsequent reperfusion injury, and that levels of circulating ectonucleotidase may reflect the severity of ischemic vascular injury.
Ischemia-reperfusion; Coronary circulation; Ectonucleotidase; ATP; Adenosine
In many studies, beta-blockers have been shown to decrease sudden cardiac death (SCD) in heart failure patients; other studies reported mixed results. Recently, several large randomized control trials of beta blockers have been carried out. It became necessary to conduct a systematic review to provide an up-to-date synthesis of available data.
We conducted a meta-analysis of all randomized controlled trials examining the use of beta-blockers vs. placebo/control for the prevention of SCD in heart failure patients. We identified 30 trials, which randomized 24,779 patients to beta-blocker or placebo/control. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Eligible studies had to be randomized controlled trials and provide information on the incidence of sudden cardiac death in heart failure patients. Additional inclusion criteria included: treatment for >30 days and follow-up ≥ 3 months. Studies of patients <18 years, randomization to beta-blocker vs. an angiotensin converting enzyme (without placebo) and/or beta-blocker in both arms were excluded from the analysis. Pre-specified outcomes of interest included SCD, cardiovascular death (CVD), and all-cause mortality and were analyzed according to intention-to-treat.
We found that beta-blockers are effective in the prevention of SCD [OR 0.69; 95% CI, 0.62–0.77, P < 0.00001], cardiovascular death (CVD) [OR 0.71; 95% CI, 0.64–0.79, P < 0.00001], and all-cause mortality [OR 0.67; 95% CI, 0.59–0.76, P < 0.00001]. Based on the study analysis, 43 patients must be treated with a beta-blocker to prevent one SCD, 26 patients to prevent one CVD and 21 patients to prevent all-cause mortality in one year.
Beta-blockers reduce the risk of sudden cardiac death (SCD) by 31%, cardiovascular death (CVD) by 29% and all-cause mortality by 33%. These results confirm the mortality benefits of these drugs and they should be recommended to all patients similar to those included in the trials.
Beta; Blocker; Sudden cardiac death; Heart failure; Meta; Analysis
Diabetic cardiomyopathy is characterized by systolic and early diastolic ventricular dysfunction. In the metabolic syndrome (MS), ventricular stiffness is additionally increased in a later stage. It is unknown whether this is related to intrinsic cardiomyocyte dysfunction, extrinsic factors influencing cardiomyocyte contractility and/or cardiac function, or a combination of both. A first aim was to study cardiomyocyte contractility and Ca2+ handling in vitro in a mouse model of MS. A second aim was to investigate whether in vivo hypocaloric diet or ACE-inhibition (ACE-I) improved cardiomyocyte contractility in vitro, contractile reserve and Ca2+ handling.
This study was performed in LDL-receptor (LDLR−/−) and leptin-deficient (ob/ob), double knock-out mice (DKO), featuring obesity, type II diabetes, atherogenic dyslipidemia and hypertension. Single knock-out LDLR−/−, ob/ob and wild type mice were used as controls. Cellular contractility, Ca2+ handling and their response to in vivo treatment with diet or ACE-I were studied in isolated cardiomyocytes at baseline, during β-adrenergic stimulation or increased extracellular Ca2+, using field stimulation and patch-clamp.
In untreated conditions, prolongation of contraction-relaxation cycle and altered Ca2+ handling are observed in MS. Response to increased extracellular Ca2+ and β-adrenergic stimulation is impaired and could not be rescued by weight loss. ACE-I restored impaired response to β-adrenergic stimulation in MS, but not the decreased response to increased extracellular Ca2+.
Cardiomyocyte contractility and β-adrenergic response are impaired in MS, due to alterations in cellular Ca2+ handling. ACE-I, but not weight loss, is able to restore cardiomyocyte response to β-adrenergic stimulation in MS.
Metabolic syndrome; Cardiomyocyte contractility; β-adrenergic stimulation; Hypocaloric diet; ACE-inhibition
The hypocholesterolemic effect of plant stanol ester consumption has been studied extensively, but its effect on cardiovascular health has been less frequently investigated. We studied the effects of plant stanol esters (staest) on arterial stiffness and endothelial function in adults without lipid medication.
Ninety-two asymptomatic subjects, 35 men and 57 women, mean age of 50.8±1.0 years (SEM) were recruited from different commercial companies. It was randomized, controlled, double-blind, parallel trial and lasted 6 months. The staest group (n=46) consumed rapeseed oil-based spread enriched with staest (3.0 g of plant stanols/d), and controls (n=46) the same spread without staest. Arterial stiffness was assessed via the cardio-ankle vascular index (CAVI) in large and as an augmentation index (AI) in peripheral arteries, and endothelial function as reactive hyperemia index (RHI). Lipids and vascular endpoints were tested using analysis of variance for repeated measurements.
At baseline, 28% of subjects had a normal LDL cholesterol level (≤3.0 mmol/l) and normal arterial stiffness (<8). After the intervention, in the staest group, serum total, LDL, and non-HDL cholesterol concentrations declined by 6.6, 10.2, and 10.6% compared with controls (p<0.001 for all). CAVI was unchanged in the whole study group, but in control men, CAVI tended to increase by 3.1% (p=0.06) but was unchanged in the staest men, thus the difference in the changes between groups was statistically significant (p=0.023). AI was unchanged in staest (1.96±2.47, NS) but increased by 3.30±1.83 in controls (p=0.034) i.e. the groups differed from each other (p=0.046). The reduction in LDL and non-HDL cholesterol levels achieved by staest was related to the improvement in RHI (r=−0.452, p=0.006 and −0.436, p=0.008).
Lowering LDL and non-HDL cholesterol by 10% with staest for 6 months reduced arterial stiffness in small arteries. In subgroup analyses, staest also had a beneficial effect on arterial stiffness in large arteries in men and on endothelial function. Further research will be needed to confirm these results in different populations.
Clinical Trials Register # NCT01315964
Arterial stiffness; Endothelial function; Cardio-ankle vascular index; Reactive hyperemia index; Augmentation index; Plant stanol ester; LDL cholesterol; Coronary artery disease
Chronic heart failure (HF) disease management programs have reported inconsistent results and have not included comorbid depression management or specifically focused on improving patient-reported outcomes. The Patient Centered Disease Management (PCDM) trial was designed to test the effectiveness of collaborative care disease management in improving health status (symptoms, functioning, and quality of life) in patients with HF who reported poor HF-specific health status.
Patients with a HF diagnosis at four VA Medical Centers were identified through population-based sampling. Patients with a Kansas City Cardiomyopathy Questionnaire (KCCQ, a measure of HF-specific health status) score of < 60 (heavy symptom burden and impaired quality of life) were invited to enroll in the PCDM trial. Enrolled patients were randomized to receive usual care or the PCDM intervention, which included: (1) collaborative care management by VA clinicians including a nurse, cardiologist, internist, and psychiatrist, who worked with patients and their primary care providers to provide guideline-concordant care management, (2) home telemonitoring and guided patient self-management support, and (3) screening and treatment for comorbid depression. The primary study outcome is change in overall KCCQ score. Secondary outcomes include depression, medication adherence, guideline-based care, hospitalizations, and mortality.
The PCDM trial builds on previous studies of HF disease management by prioritizing patient health status, implementing a collaborative care model of health care delivery, and addressing depression, a key barrier to optimal disease management. The study has been designed as an ‘effectiveness trial’ to support broader implementation in the healthcare system if it is successful.
Unique identifier: NCT00461513
Heart failure; Clinical trial; Patient reported outcomes; Quality of life; Health status
Management of cardiovascular risk factors includes commitment from patients to adhere to prescribed medications and adopt healthy lifestyles. Unfortunately many fail to take up and maintain the four key healthy behaviours (not smoking, having a balanced diet, limiting alcohol consumption and being more active). Five factors (beliefs, knowledge, transport and other costs, emotions, and friends and family support) are known to predict uptake of lifestyle behaviour change. The key factors influencing maintenance of healthy lifestyles are not known but would be helpful to support the development of relapse prevention programmes for this population. Our review aimed to clarify the main patient perceived factors thought to influence maintenance of changed healthy lifestyles.
We performed a systematic review of qualitative observational studies and applied the principles of content synthesis and thematic analysis to extract reported factors (barriers and facilitators) considered by individuals to be influential in maintaining changed healthy lifestyle behaviours. Factors were then organised into an existing framework of higher order categories which was followed by an analysis of the interrelationships between factors to identify key themes.
Twenty two studies met our inclusion criteria. Participants reported barriers and facilitators within 13 categories, the majority of which were facilitators. The most commonly reported influences were those relating to social support (whether provided formally or informally), beliefs (about the self or the causes and management of poor health, and the value of maintaining lifestyle behaviours), and other psychological factors (including attitude, thinking and coping styles, and problem solving skills). Physical activity was the most commonly investigated behaviour in four categories, but overall, the main barriers and facilitators were related to a range of behaviours. Through analysis of the interrelationships between factors within categories, ‘social support’, ‘education and knowledge’, and ‘beliefs and emotions’ were all considered key themes.
Our review suggests that for the most part, factors that influence lifestyle change are also important for maintaining healthy behaviours. This indicates that addressing these barriers and facilitators within lifestyle support programmes would also be of value in the longer-term.
Cardiovascular diseases; Lifestyle; Health behaviours; Primary prevention; Secondary prevention; Primary health care; Maintenance
Increasing rates of percutaneous coronary intervention (PCI) and decreasing rates of coronary artery bypass graft (CABG) surgery followed the introduction of drug eluting stents in Western Australia in 2002. We assessed the impact of these changes on one-year outcomes for the total population of patients undergoing coronary artery revascularisation procedures (CARP) in Western Australia between 2000-2004.
Clinical and linked administrative data (inpatient admissions and death) were merged for all patients who had their first CARP with stent or CABG in Western Australia between 2000-2004. The clinical data were collected from all hospitals in Western Australia where CARP procedures are performed. We calculated the unadjusted (Kaplan-Meier) and adjusted (Cox) risks for one-year death (all-cause), death (all-cause) or admission for myocardial infarction (MI), target vessel revascularisation (TVR) and the composite outcome of death/MI/TVR (major adverse cardiac events, MACE).
Over the study period, there were 14,118 index CARPs. The use of drug eluting stents increased from 0% to 95.8% of PCI procedures, and PCI procedures increased from 61.1% to 74.4% of all CARPS. There were no temporal changes in adjusted one-year mortality or death/MI. Overall, adjusted one-year MACE fell from 11.3% in 2000 to 8.5% in 2004 (p<0.0001) due to a significant reduction in TVR in the PCI group.
The introduction of drug eluting stents and resulting changes in coronary revascularisation strategies were not associated with changes in the one-year risk of major clinical endpoints (death or death/MI), but were associated with a significant reduction in the risk of MACE, driven entirely by a reduction in TVR after PCI. This real world study supports the effectiveness of drug eluting stents in reducing repeat procedures in the total CARP population without increasing the risk of death or MI.
Coronary artery disease; Coronary revascularisation; Clinical outcome; Population study; Drug eluting stents; Percutaneous coronary intervention
Arterial hypertension is highly prevalent but poorly controlled. Blood pressure (BP) reduction substantially reduces cardiovascular morbidity and mortality. Recent randomized, double-blind clinical trials demonstrated that azilsartan medoxomil (AZM) is more effective in reducing BP than the ubiquitary ACE inhibitor ramipril. Therefore, we aimed to test whether these can be verified under clinical practice conditions.
The “Treatment with Azilsartan Compared to ACE-Inhibitors in Anti-Hypertensive Therapy” (EARLY) registry is a prospective, observational, national, multicenter registry with a follow-up of up to 12 months. It will include up to 5000 patients on AZM or ACE-inhibitor monotherapy in a ratio of 7 to 3. A subgroup of patients will undergo 24-hour BP monitoring. EARLY has two co-primary objectives: 1) Description of the safety profile of azilsartan and 2) achievement of BP targets based on recent national and international guidelines for patients treated with azilsartan in comparison to those treated with ACE-inhibitors. The most important secondary endpoints are the determination of persistence with treatment and the documentation of cardiovascular and renal events. Recruitment commenced in January 2012 and will be completed by February 2013.
The data obtained will supplement previous results from randomized controlled trials to document the potential value of utilizing azilsartan medoxomil in comparison to ACE-inhibitor treatment for target BP achievement in clinical practice.
Azilsartan; Ramipril; ACE-Inhibitors; Non-Interventional; Blood Pressure; Follow-up; Ambulatory Blood Pressure Measurement; Central Systolic Blood Pressure
Intrathoracic schwannomas are most frequently located in the posterior mediastinum. A Chinese woman presented with a benign pericardial schwannoma in the pretracheal space and aortopulmonary window, a location which has not been described previously in the literature.
A 50-year-old Chinese woman initially reported a cough associated with a small amount of sputum. Contrast-enhanced computed tomography (CT) subsequently revealed a 9 × 11 cm2 lobulated mass with sharp margins that presented as a capsule with heterogeneous enhancement and punctate calcification. Complete surgical resection was performed using a thoracotomy approach. The resected intrapericardial tumor was a firm, large mass with lobulation. Capsulation prevented infiltration of the mass into adjacent organs. Pathological examination verified that the tumor was a benign pericardial schwannoma.
This is the first reported case of a benign pericardial schwannoma located in the pretracheal space and aortopulmonary window. While a contrast-enhanced CT scan was able to differentiate this pericardial schwannoma from other middle mediastinal tumors, the exact diagnosis and plan for treatment depended on a pathological examination. For similar cases involving pericardial schwannomas, complete surgical resection is recommended, particularly for the prevention of life-threatening cardiopulmonary complications.
Pericardium; Benign schwannoma; Computed tomography
Hypertension can be generated by a great number of mechanisms including elevated uric acid (UA) that contribute to the anion superoxide production. However, physical exercise is recommended to prevent and/or control high blood pressure (BP). The purpose of this study was to investigate the relationship between BP and UA and whether this relationship may be mediated by the functional fitness index.
All participants (n = 123) performed the following tests: indirect maximal oxygen uptake (VO2max), AAHPERD Functional Fitness Battery Test to determine the general fitness functional index (GFFI), systolic and diastolic blood pressure (SBP and DBP), body mass index (BMI) and blood sample collection to evaluate the total-cholesterol (CHOL), LDL-cholesterol (LDL-c), HDL-cholesterol (HDL-c), triglycerides (TG), uric acid (UA), nitrite (NO2) and thiobarbituric acid reactive substances (T-BARS). After the physical, hemodynamic and metabolic evaluations, all participants were allocated into three groups according to their GFFI: G1 (regular), G2 (good) and G3 (very good).
Baseline blood pressure was higher in G1 when compared to G3 (+12% and +11%, for SBP and DBP, respectively, p<0.05) and the subjects who had higher values of BP also presented higher values of UA. Although UA was not different among GFFI groups, it presented a significant correlation with GFFI and VO2max. Also, nitrite concentration was elevated in G3 compared to G1 (140±29 μM vs 111± 29 μM, for G3 and G1, respectively, p<0.0001). As far as the lipid profile, participants in G3 presented better values of CHOL and TG when compared to those in G1.
Taking together the findings that subjects with higher BP had elevated values of UA and lower values of nitrite, it can be suggested that the relationship between blood pressure and the oxidative stress produced by acid uric may be mediated by training status.
Blood pressure; Uric acid; Training status; Elderly; Oxidative stress; Nitric oxide
Subpulmonic membrane as a cause of right ventricular outflow tract obstruction in patients with concordant ventriculoarterial connection and intact ventricular septum is considered to be rare.
A 7 – year – old boy was referred to a tertiary care hospital with complaints of dyspnea on moderate exertion and palpitations of about 2 years duration. Physical examination revealed parasternal lift, systolic thrill and a 4/6 ejection systolic murmur, best heard over the left 2nd intercostal space. His oxygen saturation was 88% on room air. Two-dimensional echocardiography showed a thickened pulmonary valve with fused leaflets that show severe systolic doming. There was a discrete subpulmonic membrane about 1.3 cm below the pulmonary valve annulus. Continuous wave Doppler interrogation showed peak systolic pressure gradient of 185 mmHg across the pulmonary valve. Balloon dilation of the pulmonary valve was performed and the pressure gradient came down to 50 mmHg. Follow-up transthoracic echocardiography showed residual pressure gradient of about 50 – 60 mmHg across the pulmonary valve. The residual pressure gradient appeared to be mainly subvalvar, as seen on the continuous wave Doppler tracing. The patient reported marked improvement in terms of exercise tolerance and subjective symptoms.
Association of subpulmonic membrane with severe pulmonary valvar stenosis, concordant ventriculoarterial connection and intact ventricular septum is rare. When it occurs, the result of percutaneous valve dilation may be suboptimal.
Subpulmonic membrane; Right ventricular outflow; Pulmonary stenosis; Percutaneous valvotomy
The combination of the new high sensitivity troponin T (hsTnT) assays and copeptin, a biomarker of endogenous stress, has been suggested to have the potential of early rule-out of acute coronary syndrome (ACS). The aim of this study was to examine the ability of this combination to rule out ACS in patients presenting with chest pain and to compare the diagnostic performance to hsTnT alone.
In this prospective observational study, patients with chest pain admitted for observation were consecutively included. Patients presenting with ST elevation were excluded. Copeptin and hsTnT were analyzed at admission and hsTnT was thereafter determined approximately every 3rd hour as long as clinically indicated. The follow-up period was 60 days. A combined primary endpoint of ACS, non-elective percutanous coronary intervention, non-elective coronary artery bypass surgery and death of all causes was used.
478 patients were included. 107 (22%) patients were diagnosed with ACS during hospital stay. 70 (14%) had non-ST-segment elevation myocardial infarction (NSTEMI) and 37 (8%) had unstable angina pectoris (UAP).
The combination of hsTnT >14 ng/L or copeptin ≥14 pmol/L at admission identified ACS with a higher sensitivity than hsTnT alone: 0.83 (95% confidence interval (CI): 0.74-0.89) versus 0.69 (95% CI: 0.59-0.77), p <0.001. Negative predictive values (NPV) 91% (95% CI: 86-94) versus 89% (95% CI: 84-92). A repeated hsTnT analyzed 3-4 hours after admission resulted in a sensitivity of: 0.77 (95% CI: 0.65-0.86), p =0.031 for comparison with the combination analyzed at admission.
In patients presenting with chest pain admitted for observation, the combination of hsTnT and copeptin analyzed at admission had a significantly higher sensitivity to diagnose ACS than hsTnT alone. We report a sensitivity of 83% and a NPV of 91% for the combination of hsTnT and copeptin and we conclude that biomarkers alone are not sufficient to rule out ACS. However, the combination of hsTnT and copeptin seems to have a significantly higher sensitivity to identify ACS than a repeated hsTnT test, and thus enables an earlier risk stratification of chest pain patients. This can be time-saving and beneficial for the individual patient by contributing to early decisions on treatment, need of further assessment and level of care.
Copeptin; High sensitivity troponin; Acute coronary syndrome; Emergency department
the objective of this study is to investigate the detection rate of undiagnosed atrial fibrillation (AF) with short intermittent ECG recordings during four weeks among out-of-hospital patients, having at least one additional risk factor (CHADS2) for stroke.
Design: Cross-sectional study. Setting: Eight family practice centres and two hospital-based out-patient clinics in Sweden. Subjects: 989 out-of-hospital patients, without known AF, having one or more risk factors associated with stroke (CHADS2). Interventions: All individuals were asked to perform 10-second handheld ECG recordings during 28 days, twice daily and when having palpitations. Main outcome measures: Episodes of AF on handheld ECG recordings were defined as irregular supraventricular extrasystoles in series with a duration of 10 seconds.
928 patients completed registration. AF was found in 35 of 928 patients; 3.8% (95% confidence interval [CI] 2.7–5.2). These 35 patients had a mean age of 70.7 years (SD ± 7.7; range 53–85) and a median CHADS2 of 2 (range 1–4).
Intermittent handheld ECG recording over a four week period had a detection rate of 3.8% newly diagnosed AF, in a population of 928 out-of-hospital patients having at least one additional risk factor for stroke. Intermittent handheld ECG registration is a feasible method to detect AF in patients with an increased risk of stroke in whom oral anticoagulation (OAC) treatment is indicated.
Arrhythmia; Atrial fibrillation; Handheld ECG; Stroke prevention; Screening
Mean platelet volume has been associated with stroke in patients with atrial fibrillation. However, its role as a predictor of left atrial stasis, assessed by transesophageal echocardiography, in patients with non-valvular atrial fibrillation has not yet been clarified.
Single center cross-sectional study comprising 427 patients admitted to the emergency department due to symptomatic atrial fibrillation and undergoing transesophageal echocardiogram evaluation for exclusion of left atrial appendage thrombus before cardioversion. All patients had a complete blood count performed in the 12 hours prior to transesophageal echocardiogram. Markers of left atrial stasis were sought: left atrial appendage thrombus, dense spontaneous echocardiographic contrast and low flow velocities in the left atrial appendage. The presence of at least one of the former markers of left atrial stasis was designated left atrial abnormality. Binary logistic multivariate analysis was used for obtaining models for the prediction of transesophageal echocardiogram endpoints.
Left atrial appendage thrombus was found in 12.2%, dense spontaneous echocardiographic contrast in 29.7%, low flow velocities in 15.3% and left atrial abnormality in 34.2%. Mean platelet volume (exp β = 3.41 p = 0.048) alongside with previous stroke or transient ischemic attack (exp β = 5.35 p = 0.005) and troponin I (exp β = 5.07 p = 0.041) were independent predictors of left atrial appendage thrombus. Mean platelet volume was also incorporated in the predictive models of dense spontaneous echocardiographic contrast, low flow velocities and left atrial abnormality, adding predictive value to clinical, echocardiographic and laboratory variables.
These findings suggest that mean platelet volume may be associated with the presence of markers of left atrial stasis, reinforcing a likely cardioembolic mechanism for its association with stroke in patients with non-valvular atrial fibrillation.
Atrial fibrillation; Stroke; Left atrial appendage thrombus; Mean platelet volume