Cardiovascular Internal Medicine Research Articles

Abstract 177: Credentials of Staff Performing Echocardiography in the United States: Insights from the Intersocietal Accreditation Commission

Background: Little has been published on the practice of echocardiography (echo) in the United States. We used the Intersocietal Accreditation Commission-Echocardiography (IAC-Echo) applications database to describe the personnel in echo laboratories seeking accreditation. Methods: We used de-identified data provided on IAC-Echo applications to characterize facilities by hospital association, census region, annual volume, number of sites, previous accreditation, and numbers of physicians and sonographers as well as National Board of Echocardiography (NBE) testamur status of physicians and registered credential status of sonographers. We categorized Medical Directors by board certification in cardiovascular diseases, internal medicine, other specialty, or none. Medical Director echo training could be formal Level 2 or 3 or experiential by ≥3 years of practice. Frequencies, means, and medians were compared between groups using the chi-square test, t-test, or Mann Whitney test, respectively. Results: From 2011 to 2013, 1926 echo labs representing 10618 physicians and 6870 sonographers applied for IAC-Echo accreditation or re-accreditation. The majority of medical directors were board certified in cardiovascular diseases and 34.1% of medical directors and 27.2% of staff physicians held NBE testamur status; 79.5% of sonographers held registered credentials. Most echo labs were in the Northeast or South census regions, have an average of 1.75 sites, and are based outside of hospitals (Table). Compared to nonhospital echo labs, medical directors of hospital-based echo labs were more likely to be Level 3 trained (19.8% versus 30.8%, p<0.01) and be NBE testamurs (28.9% versus 45.6%, p<0.01). Markers of echo lab size, region, previous accreditation, and credentialed sonographers were associated with accreditation versus delay decisions; there was a trend toward accreditation among facilities with NBE medical directors. Conclusion: Among facilities seeking IAC-Echo accreditation, the minority of echo physicians hold NBE testamur status. Hospital and nonhospital facilities are different in the credentials of their personnel.

Our Treatment Strategy for Critical Limb Ischemia

For the treatment of critical limb ischemia, collaboration with wound specialists and cardiologists performing revascularization is important. The foot care unit affiliated with related departments opened at our hospital in July 2010 for limb salvage, mainly under the leadership of the departments of cardiovascular internal medicineand plastic surgery. We have treated 194 patients up until October 2012. The primary diseases included 81 cases (87 limbs) of foot ulcer and gangrene, with complications of peripheral arterial diseases (PADs) in all cases. Intravascular treatment was conducted for 69 limbs with PAD complications, and the initial success rate was 85.5%, of which surgical debridement or minor amputation was performed on 32 limbs. Regarding open wounds following operation and chronic ulcer, platelet-rich plasma therapy was conducted in 29 limbs and negative pressure wound therapy in 15 limbs. Among all of the patients treated, 58 limbs healed, 10 cases died, and the others are currently receiving ongoing treatment. Cardiovascular internal medicine specialists and plastic surgeons examine patients together at the outpatient clinic and prepare and implement a multidisciplinary treatment plan including vascular reconstructions and operation. We cooperate with physicians in each related department and efforts in team medicine have been made for the purpose of limb salvage.

重症下肢虚血に対する当院の治療戦略：循環器内科，形成外科を中心とした取り組み

重症下肢虚血患者の創傷治療には血流の改善を図る医師と創傷の管理を行う医師の協力が不可欠である．当院では，2010年7月から循環器内科，形成外科が中心となり関連各科と連携したフットケア外来を開設した．2011年10月までに外来を受診した患者の総数は105名で，重症下肢虚血にともなう足部皮膚潰瘍・壊疽は48例/51肢であった．41肢に血管内治療を行い，初期成功率は85.3%で，19肢に外科的デブリードマンや小切断術を施行した．術後の開放創や創傷治癒が停滞した潰瘍に対しては，通常の軟膏等による保存的加療のほか，多血小板血漿療法を20肢，持続陰圧閉鎖療法を6肢に行った．これら全CLI症例の治療経過は，治癒30肢，加療中3肢，死亡10例(18肢)であった．フットケア外来では，循環器内科医，形成外科医が一緒に診察し，血行再建から手術を含めた集学的治療計画を立て，実践している．二診療科が密接した連携を図ることで，より低侵襲で安全，かつ治療期間の短縮を目的としたチーム医療が可能と思われた．

Follow‐up study for a disease management program for chronic heart failure 24 months after program commencement

There are few studies dealing with comprehensive chronic heart failure (CHF) disease management programs, which are based on self-management, in Japan. We developed and conducted a comprehensive educational program for CHF for 6 months that aimed to improve self-management and prevent the deterioration of outpatients with CHF. Our follow-up research focused on whether performance of self-management in the intervention group continued for 24 months after commencement. Participants were selected from patients who went for follow-up visits to one Japanese clinic, which specialized in cardiovascular internal medicine, that were diagnosed with CHF. During the first follow-up period, 7 to 12 months after program commencement, 47 participants in the intervention group and 47 participants in the control group were analyzed. During the second follow-up period, 13 to 24 months after program commencement, 41 participants in the intervention group were analyzed. Participants in the intervention group acquired self-management skills and activities and these continued up to 24 months after the program commencement. As a result, no deterioration in symptoms related to CHF was demonstrated. Meanwhile, quitting smoking and drinking depended on individual preference and it was difficult to improve. The educational program was effective in the long term and the program is significant for use in busy medical situations that do not offer sufficient follow-up support for patients. Regular intervention and ways that produce longer-lasting effects should be further developed.

LAG STRUCTURE AND HARVESTING EFFECTS OF AIR POLLUTION ON DAILY OUTPATIENT VISITS

Background and Aims: To explore whether there is harvesting effect between air pollutants and daily outpatient visits in Zhengzhou. Methods: We collected air quality data, weather data and daily outpatient visits for the department of respiratory medicine, cardiovascular internal medicine and neurology from December 1, 2008 to November 30, 2009 in Zhengzhou, and then used generalized linear distributed lag models to explore the relationship between air pollutants and daily outpatient visits, after adjusting confounding effects of long-term and seasonal trend, daily temperature and relative humidity. Results: PM10 and NO2 were significantly associated with daily outpatient visits for the department of cardiovascular internal medicine. An increase of 10 μg/m3 in PM10 was associated with an ER of 3.55% (95% CI: 0.28%~6.93%) outpatient visits for the department of cardiovascular internal medicine. And an increase of 10 μg/m3 in NO2 was associated with an ER of 17.72% (95% CI: 2.84%~13.48%) outpatient visits for the department of cardiovascular internal medicine. We didn’t observe harvesting effects between PM10 and NO2, and daily outpatient visits for the department of cardiovascular internal medicine. PM10, SO2 and NO2 were not significantly associated with daily outpatient visits for the respiratory internal medicine and neurological internal medicine. Also, SO2 was not significantly associated with daily outpatient visits for the department of cardiovascular internal medicine. Conclusion: Daily PM10 and NO2 concentration were positively associated with daily outpatient visits for the department of cardiovascular internal medicine in Zhengzhou, and there is no harvesting effect.

Risk factors for intracerebral hemorrhage and coronary heart diseases over a 3-year period in patients admitted to some hospitals of Tongliao city of Nei Monggol Autonomous Region: Retrospective analysis on case data

Background Intracerebral hemorrhage(ICH) and coronary heart disease (CHD) have the same pathological base, atherosclerosis, and the similar risk factors, such as smoking, drinking, hypertension, hyperlipemia, diabetes mellitus, etc; but the distributions of two diseases are very different in the populations. This may be related to the exposure of risk factors and different effects of risk factors on two diseases. Objective To analyze the distribution difference of risk factors for ICH and CHD in the populations of Tongliao city of Nei Monggol Autonomous Region. Design Retrospective analysis. Setting School of Radiation Medicine and Public Health, Soochow University; Tongliao Hospital, Nei Monggol Autonomous Region. Participants Random sampling was used to select 6 hospitals from 10 hospitals affiliated to Tongliao City of Nei Monggol Autonomous Region. Totally 1 672 medical records of patients with ICH and 2 195 medical records of patients with CHD admitted to Department of Neurology and Department of Cardiovascular Internal Medicine of above-mentioned 6 hospitals between January 2003 and December 2005 were collected according to the investigation need. Methods The subjects, whose medical records were involved, were performed retrospective analysis with pre-prepared questionnaire “ Stroke and Coronary Heart Disease Epidemiologic Questionnaire”. The main contents included: ▪Social demography condition: The distributions of gender, age, nationality, etc. ▪Previous history of disease: hypertension, diabetes mellitus, etc. ▪Related risk factors: systolic blood pressure, diastolic blood pressure, total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, smoking, drinking and glucose (GLU). The database of Epidata was transformed to SPSS database. Single-and multiple-factor non-conditional Logistic regression analysis were performed on the data, and OR value and 95% CI were calculated. The distribution differences of risk factors for two diseases were compared. Main outcome measures Single- and multi-factor non-conditional Logistic regression analysis results of each factor of patients. Results Single-factor non-conditional Logistic regression analysis showed that statistical significance existed in gender, age, nationality, smoking, drinking, history of hypertension, history of diabetes mellitus, hypertension, triglyceride (TG), and GLU ten factors( OR = 0.199, OR 95% CI 0.142–0.280 to OR =7.484, OR 95% CI 6.186–9.054, P < 0.01). ▪The results of multiple-factor non-conditional Logistic regression analysis showed 8 factors including age, gender, smoking, hypertension, history of hypertension, history of diabetes mellitus, GLU and TG( OR =0.203, OR 95% CI 0.114–0.361 to OR =8.262, OR 95% CI 5.466–12.491, P < 0.01). Conclusion ICH and CHD are the diseases induced by various risk factors. Significant difference exists in gender, age, smoking, hypertension, history of hypertension, GLU, history of diabetes mellitus and TG.

Carvedilol accelerate elevation of serum potassium in chronic heart failure patients administered spironolactone plus furosemide and either enalapril maleate or candesartan cilexetil

To retrospectively investigate the effect of carvedilol and spironolactone plus furosemide, administered concomitantly with an angiotensin II converting enzyme inhibitor (ACE-I) or an angiotensin II receptor blocker (ARB) to patients with chronic heart failure (CHF). Patients with CHF, who visited Departments of Cardiovascular Internal Medicine at the National Hospital Organization Osaka Medical Center, were enrolled for this study. Serum potassium, blood urea nitrogen (BUN), serum creatinine (Scr) and serum sodium were measured in every patient at the time of start of treatment and after 3 and 12 months of treatment. Data from patients in groups A (20 mg/day carvedilol + 25 mg/day spironolactone + 40 mg/day furosemide + an ACE-I) and B (20 mg/day carvedilol + 25 mg/day spironolactone + 40 mg/day furosemide + ARB) were compared. When 20 mg/day carvedilol plus 25 mg/day spironolactone plus 5 mg/day enalapril maleate (enalapril, group A) or 8 mg/day candesartan cilexetil (candesartan, group B) plus 40 mg/day furosemide were used concomitantly, the mean serum potassium increased significantly in both groups of patients. Seven of 59 (11.9%) patients had hyperkalemia (>5.5 mEq/L) during 12 months of treatment whereas 8.5% of patients (five of 59) had hypokalemia (< or =3.5 mEq/L). When carvedilol is used concomitantly with spironolactone, furosemide and enalapril or candesartan, it is necessary to monitor serum potassium concentration, even if spironolactone is administered at a low dose of 25 mg/day.

• Recapping Highlights from the 2006 PHA Scientific Sessions• Reviewing New Perspectives on Inflammation, Genetics, and Imaging• Redefining Exercise-Induced PH• Future Considerations in Translational Research

This discussion was moderated by Karen A. Fagan, MD, Associate Professor of Medicine, University of Colorado Health Sciences Center, Denver, Colorado. Panel members included David B. Badesch, MD, Professor of Medicine, Divisions of Pulmonary Sciences &amp; Critical Care Medicine, and Cardiology Clinical Director, Pulmonary Hypertension Center, University of Colorado Health Sciences Center, Denver, Colorado; C. Gregory Elliott, MD, Professor of Medicine, University of Utah School of Medicine, Pulmonary Division, LDS Hospital, Salt Lake City, Utah; and Robert P. Frantz, MD, Assistant Professor of Medicine, Mayo Clinic College of Medicine, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota.

Serum concentration of potassium in chronic heart failure patients administered spironolactone plus furosemide and either enalapril maleate, losartan potassium or candesartan cilexetil

To retrospectively investigate elevation of serum potassium when spironolactone (25 or 50 mg/day) and furosemide were administered concomitantly with an angiotensin II converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) to patients with chronic heart failure for 12 months and occurrence of hyperkalemia and hypokalemia because of concomitant administration of spironolactone plus an ACE-I or ARB and furosemide. Patients with chronic heart failure, who visited departments of cardiovascular internal medicine and cardiovascular surgery at the National Hospital Organization Osaka Medical Center, were enrolled for this study. Serum potassium, blood urea nitrogen (BUN), serum creatinine, uric acid, and serum sodium were determined in every patient at the time of start of treatment and at 3 and 12 months of treatment. Data from patients in Groups A (25 mg/day spironolactone + 40 mg/day furosemide + an ACE-I or ARB) and B (50 mg/day spironolactone + 40 mg/day furosemide + an ACE-I or ARB) were analysed for differences with respect to the ACE-I and ARB used. When 50 mg/day spironolactone plus 5 mg/day enalapril maleate (enalapril) or 50 mg/day losartan potassium (losartan) or 8 mg/day candesartan cilexetil (candesartan) plus 40 mg/day furosemide were concomitantly used, the mean value of serum potassium was significantly elevated only in the group treated with 50 mg/day spironolactone regardless of the concomitant drug. The number of patients with hyperkalemia (>5.5 mEq/L) at 12 months of treatment was 12 (8.8%), while the number of patients with hypokalemia (<or=3.5 mEq/L) was 7 (5.1%). However, the occurrence of hyperkalemia was almost the same regardless of the dose of spironolactone or the ACE-I or ARB concomitantly administered. Therefore, if enalapril, losartan, or candesartan is concomitantly used, it is necessary to monitor the serum concentration of potassium, even if spironolactone is administered at a dose of 25 mg/day. The occurrence of hyperkalemia in patients administered spironolactone is influenced by the dose, but when it is used concomitantly with enalapril, losartan or candesartan, the occurrence of hyperkalemia exceeding 5.5 mEq/L may increase even if the dose of spironolactone is as low as 25 mg. Thus it is essential to always monitor serum potassium.

Research of the relationship between smoking and peripheral arterial disease

To investigate the relationship between smoking and peripheral arterial disease (PAD) by investigate the smoking status and measuring the (ABI). A questionnaire survey was conducted among 3379 male patients hospitalized in the departments of cardiovascular internal medicine, nephrology, and endocrinology, aged 40-98, 2253 smokers and 1126 non-smokers, to understand their life styles, anamnesis, and smoking history. All patients underwent measurement of systolic blood pressures of the upper arm and ankle so as to calculate the ankle-brachial index (ABI). Measurement. An ABI less than or equal to 0.9 was considered to be indicative of significant PAD. The ABI levels in the smoker group were significantly lower than those in the non-smoker group (P < 0.05). The prevalence of PAD was 24.94% in the smoker group, and 20.60% in the non-smoker group. The age-adjusted OR of the smokers was 1.480 (95% CI: 1.237-1.770), with a significant dosage-effect relationship between smoking and PAD. Smoking is a significant risk factor of PAD. The prevalence of PAD was increased with the dosage of smoking.

Recapping Highlights from Pulmonary Hypertension Association Scientific Sessions and Identifying Key Issues Driving Translational Research

This discussion was moderated by Michael McGoon, MD, Professor of Medicine and Consultant in the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota. Participants included members of the Editorial Advisory Board of Advances in Pulmonary Hypertension: Victor F. Tapson, MD, Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, and Editor-in-Chief of the journal; Richard N. Channick, MD, Associate Professor of Medicine, Pulmonary and Critical Care Division, University of California, San Diego Medical Center, San Diego, California; Vallerie V. McLaughlin, MD, Associate Professor of Medicine, Director, Pulmonary Hypertension Program, University of Michigan Health System, Ann Arbor, Michigan; Ronald J. Oudiz, MD, Associate Professor of Medicine, UCLA School of Medicine, and Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, Harbor-UCLA Medical Center, Torrance, California; and Ivan M. Robbins, MD, Director, Pulmonary Hypertension Center, Vanderbilt University, Nashville, Tennessee.

Impact of Increasing Diabetes on Coronary Artery Disease in the Past Decade

We studied the coronary risk factors of hospitalized patients with coronary artery disease (CAD) in the Department of Cardiovascular Internal Medicine of Kobe University Hospital in 1993, 1996, 1999 and 2003, and examined trends in the factors over the past decade. The prevalences of diabetes mellitus (DM) (24.7%, 33.6%, 41.1% and 44.7%, respectively) and impaired glucose tolerance (IGT) (5.9%, 8.0%, 9.3% and 11.0%, respectively) steadily increased, whereas dyslipidemia (high total cholesterolemia, high triglyceridemia, or low high-density lipoproteinemia) and hypertension remained unchanged. We also revealed an increase in hemoglobin A1c levels (5.8%, 5.9%, 6.2% and 6.4%, respectively), in contrast to modest improvements in lipid levels and blood pressure levels. Additionally, patients with multi-vessel disease (MVD, stenosis in more than two major coronary vessels) significantly increased from 44.7% in 1993 to 58.8% in 2003 (p < 0.01). In 1993, DM and dyslipidemia were significant predictors for MVD (Odds Ratio: 2.72 and 2.68, respectively). On the other hand, in 2003, the significant predictor for MVD shifted to DM alone (Odds Ratio: 2.38). In conclusion, the prevalence rate of DM among CAD patients significantly increased in this decade, and the consequent increase in the prevalence of MVD should be recognized as the most important problem clinically.

Evaluation of myocardial blood flow reserve in patients with chronic congestive heart failure due to non-ischemic cardiomyopathy

Evaluation of Myocardial Blood Flow Reserve in Patients with Chronic Congestive Heart Failure Due to Non-Ischemic Cardiomyopathy Mohammed W. Akhter, Menahem Canetti, Amir Lerman, Ilyas S. Karaalp, Jason A. Zell, Harpreet Singh, Anilkumar Mehra, Uri Elkayam1—Division of Cardiovascular Medicine, University of Southern California, Los Angeles, CA; Division of Cardiovascular Medicine & Internal Medicine, Mayo Clinic Rochester, Rochester, MN

Artery-Expanding Stents Widen Hopes for Patients With Atherosclerosis

"IT MAKES GOOD SENSE to try these stents," Ronald E. Vlietstra, MD, said at the annual American Heart Association meeting in Anaheim, Calif. Vlietstra, a consultant in cardiovascular disease and internal medicine at the Mayo Clinic, Rochester, Minn, was recommending consideration of the newest idea for maintaining patency in atherosclerotic coronary arteries. A stent is a small stainless steel device—about the size of a spring in the old ballpoint pens—designed to be placed permanently in an artery so that it acts as a supporting framework to keep the walls apart, permitting the blood to circulate without obstruction. Three different types of stents were described at the meeting by investigators who think the devices, still in an early stage of development, may one day be used routinely to prevent the restenosis that occurs within six months in up to 30% of some 200 000 patients with cardiovascular disease who undergo percutaneous