Cardiovascular Outpatient Clinic Research Articles

Evaluation of medication appropriateness index in cardiovascular outpatient clinic: A cross-sectional study.

Older adults often have polypharmacy and multimorbidity. Cardiovascular diseases (CVDs) are the most common multimorbidities in older adults and are linked to wide range of adverse drug effects and drug-related problems. The medication appropriateness index (MAI) has been widely used in several patient settings to assess Potentially Inappropriate Medication (PIM) prescribing in older adults. The purpose of this study was to evaluate PIM prescribing in cardiovascular disease outpatient clinic. It also aimed at assessing the validity of the MAI to detect and quantify PIMs specifically in CVD outpatient clinics. This was a cross-sectional, single-center study in cardiovascular outpatient setting. Demographic, clinical, and medication information from older adults (≥ 65years old) were collected and reviewed. Two clinical pharmacists randomly selected 70 patients, evaluated 539 medications, and assessed their appropriateness using the MAI. The Statistical Package for the Social Sciences (SPSS) descriptive and logistic regression analyses was to calculate the number of PIMs, the MAI scores, and factors associated with PIM prescribing. Our data showed that 87.1% of patients had at least one PIM and the number of PIMs per patient was 2.10. Approximately 60% of the patients had an MAI weighted score of zero (no prescription error). The mean MAI score per patient was 17.61 and the mean MAI score per medication was 2.72. The overall agreement between the two raters was 87.3% with moderate chance-adjusted agreement as indicated by the kappa static of 0.43. The factors that were associated with increased PIM prescribing were the total number of medications and being ≥85years old. A relatively high prevalence of PIMs was found in the studied population. The MAI is a reliable and valid tool to detect PIM prescribing in CVD outpatient clinics. It mandates implementing specific measures to reduce PIMs.

#614 Identifying distinct patient phenotypes in patients with chronic kidney disease

Abstract Background and Aims Patients with chronic kidney disease (CKD) are heterogeneous in terms of age, causes of CKD, and comorbidities. Although individual risk factors greatly influence patients’ risk of clinical outcomes, this heterogeneity is rarely used to guide clinical decision-making. In this study we aimed to derive phenotypes in patients with CKD based on characteristics commonly available in routine clinical practice and evaluated whether these phenotypes were associated with clinical outcomes. Method Patients from the Utrecht Patient Oriented Database (UPOD) who were 18 years or older with CKD (defined as an eGFR <60 ml/min/1.73 m2 or an UACR > 3 mg/mmol present for >3 months) and visited one of the cardiovascular outpatient clinics of the University Medical Center Utrecht between 2012 and 2019 were included. Patient phenotypes were derived with latent class analyses based on age, sex, CKD stage, cause of kidney disease, and (cardiovascular) comorbidities. The incidence rate/100 person years (IR/100PY) for all-cause mortality and kidney failure (defined as initiation of kidney replacement therapy or a sustained eGFR <15) and 95% confidence interval (95% CI) was calculated for each phenotype. Results Overall 9005 patients were included (mean age 65 ± 14 years, 42% women, mean estimated glomerular filtration rate (eGFR) 49 ± 17 ml/min/1.73 m2). The median follow-up was 3.8 years [interquartile range 1.8–6.4]. Latent class analysis identified 7 phenotypes with the following characteristics: phenotype 1 were young patients with primary kidney disease (10%); phenotype 2 were patients with diabetes and a preserved eGFR (9%); phenotype 3 were patients with low comorbidity and inflammation (28%); phenotype 4 were older patients with a history of cardiovascular disease (27%); phenotype 5 were older patients with a history of cardiovascular disease and severe CKD (16%); phenotype 6 were younger patients with a kidney transplant and low comorbidity (6%); and phenotype 7 were older patients with a kidney transplant and cardiovascular disease (6%). The risk of all-cause mortality and kidney failure differed significantly between the identified phenotypes. The phenotypes of younger kidney transplant recipients, younger patients with primary kidney disease, and diabetes with preserved eGFR had the lowest risk for all-cause mortality (for all, IR/100 PY <5) (Fig. 1). The phenotypes with an intermediate incidence rate for all-cause mortality were the low comorbidity and inflammation phenotype (IR/100PY 7.4, 95% CI 6.9–8.0), the phenotype of older patients with cardiovascular disease (IR/100PY 7.2, 95% CI 6.7–7.8), and the phenotype of older patients with a kidney transplant and cardiovascular disease (IR/100PY 6.5, 95% CI 5.5–7.6). The phenotypes with highest incidence rate for all-cause mortality was the phenotype of older patients with cardiovascular disease and severe CKD (IR/100PY 12.5, 95% CI11.5–13.4). The phenotypes with the lowest risk for kidney failure were the diabetes phenotype, the low comorbidity and inflammation phenotype, and the phenotype of older patients with cardiovascular disease (all IR/100 PY <1). The phenotype of older patients with cardiovascular disease and severe CKD also had the highest risk to develop kidney failure (IR/100PY 5.8, 95% CI 5.1–6.6), followed by the phenotype of patients with primary kidney disease (IR/100PY 4.4, 95% CI 3.7 −5.5). Conclusion We identified 7 different phenotypes of patients with CKD including 2 phenotypes of patients with a kidney transplant with different clinical characteristics and prognosis. The differences in risk of all-cause mortality and kidney failure warrants a different monitoring and follow-up across the different phenotypes within the setting of CKD. Future studies should invest In evaluating the implementation of our identified phenotypes in routine clinical practice or clinical trial design with respect to differences in treatments.

#615 Generalisability of cardiovascular RCTs to patients with chronic kidney disease in clinical practice: a comparison between RCTs and real-world data

Abstract Background and Aims Randomised controlled trials (RCTs) often apply stringent eligibility criteria, which could limit the external applicability of RCTs to patients in routine clinical practice. This is specifically troublesome in the setting of chronic kidney disease (CKD) given that kidney disease is commonly used as an ineligibility criterion in RCTs. In this pilot study we estimated the eligibility of patients with CKD in routine clinical practice in five major cardiovascular outcome trials - CREDENCE, DAPA-CKD, CIBIS II, CIBIS III, and AUGUSTUS - and described reasons for ineligibility. Method We included patients with CKD (defined as an estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 or an urinary albumin creatinine ratio (UACR) >3 mg/mmol present for >3 months) from the Utrecht Patient Oriented Database (UPOD) who visited a cardiovascular outpatient clinic in the University Medical Centre Utrecht between 2012 and 2019. The eligibility criteria were extracted from the selected RCTs and consequently modelled on the patients from UPOD. The percentage of eligible patients and reasons for ineligibility were described descriptively. The percentage of eligible patients for CIBIS II and CIBIS III were only calculated for patients with heart failure, and for the AUGUSTUS trial for patients with coronary artery disease as patients with these conditions were targeted. Patients could not fulfil multiple inclusion criteria and or meet multiple exclusion criteria or both. Results In total, 9005 UPOD patients with CKD were included. Patients had a mean age of 65 ± 14 years, 42% was female, mean eGFR was 49 ± 17, 1741 (19%) had a history of atherosclerotic cardiovascular disease, and 765 (8%) of heart failure. Overall, 0.05% of patients would be eligible for the DAPA-CKD trial and 0% for the CREDENCE trial. Of included patients with heart failure, 2% would have been eligible for CIBIS II and 3% for CIBIS III. Of included patients with coronary artery disease, 2% would have been eligible for the AUGUSTUS trial. Main reasons for ineligibility for DAPA-CKD were not fulfilling the inclusion criteria for UACR (52%), eGFR (20%), or the prescription of RAAS-inhibitors (arb) (49%) or meeting the exclusion criteria for primary kidney disease (PRD, 6%), or a kidney transplant (15%), or other comorbidities. Similarly, patients were often ineligible for the CREDENCE trial because they did not fulfill the inclusion criteria for UACR (48%), eGFR (18%), HbA1c (35%), or prescription of a RAAS-inhibitor (43%) or met one of the exclusion criteria for PRD (29%), cardiovascular disease (23%), or prescription of a mineralocorticoid receptor antagonist (10%). For CIBIS II, main reasons for ineligibility were not fulfilling the inclusion criteria for left-ventricular ejection fraction (LVEF, 50%) or prescription of an ace-inhibitor (42%) or diuretic (33%) or meeting the exclusion criteria of coronary artery disease (17%) or prescription of a calcium-channel blocker (16%). For CIBIS III, patients were also ineligible because they were not fulfilling the inclusion criteria for age (46%), LVEF (46%), or prescription of diuretics (31%) or met the exclusion criteria for serum creatinine (9%) or prescription of an angiotension receptor blocker (14%). Lastly, for the AUGUSTUS trial, patients were mainly ineligible due to not fulfilling the inclusion criteria of atrial fibrillation (79%) or percutaneous coronary interventions (PCI, 91%) or meeting the eGFR exclusion criteria (14%). Conclusion Based on this pilot study, less than 3% of patients with CKD in routine clinical practice would be eligible to participate in cardiovascular RCTs. Patients were often ineligible because they did not fulfil the inclusion criteria and a substantial number of patients was ineligible due to kidney disease. The low eligibility rate of patients with CKD in cardiovascular trials could limit the generalisability of results to patients with CKD treated in practice. To improve generalisability, RCTs in patients with CKD should aim to include more patients who reflect the patients with CKD treated in practice.

Translation, adaptation, and validation of a Chinese version of the Hypertension Self-Care Activity Level effects (H-SCALE) for patients with hypertension.

Lifestyle modification is an essential component of prevention and management of hypertension. Existing instruments in Taiwan focus on assessing lifestyle modifications by evaluating medication adherence or confidence in controlling blood pressure. However, other self-care activities, such as diet, physical activity, weight management, smoking, and alcohol consumption are also important. The Hypertension Self-Care Activity Level Effects (H-SCALE) is one such instrument, but there are no similar tools available in Taiwan. This study aimed to translate the H-SCALE into Chinese and test its validity, and reliability in a sample of adults with hypertension. The English version of the 31-item H-SCALE was translated into Chinese using the forward-backward method. The content validity index (CVI) of the translated scale was determined by five experts in hypertension. Item analysis was conducted with a pilot sample of 20 patients with hypertension. Cronbach's α was used to establish the internal consistency reliability for the Chinese version of the H-SCALE (H-SCALE-C). Exploratory factor analysis (EFA) explored the structure of the H-SCALE-C. Additionally, construct validity was examined with confirmatory factor analysis (CFA). Patients with hypertension were recruited by convenience sampling from a cardiovascular outpatient clinic of a medical center in northern Taiwan. A total of 318 patients met the inclusion criteria and participated in factor analysis in the study. Pilot testing of the scale items indicated most patients could not accurately estimate the number of days of alcohol consumption for the previous week. Therefore, three alcohol-related items were removed. The adaptation resulted in a 28-item H-SCALE-C. EFA revealed a 4-factor solution with 13 items that explained 63.93% of the total variance. CFA indicated a good fit for a 4-factor model and construct validity was acceptable. Internal consistency reliability was acceptable (Cronbach's alpha for the four subscales ranged from 0.65 to 0.94). Convergent validity was acceptable, and discriminant validity was significant. The H-SCALE-C is a valid, reliable tool for promptly assessing life-style activities for patients with hypertension in Taiwan. The instrument is suitable for assisting healthcare providers in evaluating self-care activities, which could be used to facilitate lifestyle modifications for patients with hypertension.

Mediating Effect of Heart Rate Variability on the Relationship Between Anxiety Symptoms and Blood Pressure in Patients with Primary Hypertension.

Patients with hypertension (HTN) are at increased risk of developing cardiovascular disease, which can be reduced with blood pressure (BP) control. Anxiety can contribute to high BP and low heart rate variability (HRV). Although relationships between social support, self-rated health-status (SRHS), anxiety and measures of HRV and BP have been suggested, they have not been clearly established. This cross-sectional correlational study aimed to 1) examine relationships between social support, SRHS, and anxiety; and 2) examine if HRV mediated relationships between anxiety symptoms and BP. Patients with primary HTN were recruited from a cardiovascular outpatient clinic using convenience sampling (N = 300). Data included scale scores for SRHS, social support, and anxiety (Hospital Anxiety and Depression Scale). A handheld limb-lead electrocardiogram monitor measured HRV, using the ratio of low-frequency bands to high-frequency bands; an automatic sphygmomanometer measured systolic and diastolic blood pressure (SBP and DBP, respectively). Path analysis of structural equation models examined relationships between variables; the bootstrap method examined the mediating effects of HRV. Analysis showed scores for SRHS and social support had a direct effect on anxiety scores. Scores for anxiety directly affected HRV and BP. HRV also had a direct effect on BP. Bootstrapping indicated HRV mediated the relationship between anxiety symptoms and BP. The final model indicated SRHS, social support, and anxiety symptoms together explained 80% of SBP and 33% of DBP. These findings suggest HRV could be used to measure the effectiveness of strategies aimed at reducing anxiety and improving control of BP.

Is hemolysis a predictor of complications in patients implanted with a left ventricular assist device?

Aim: Life-threatening complications such as intra-device thrombus, infection, bleeding, kidney and liver failure are frequently encountered due to the use of left ventricular assist devices (LVADs). We aimed to determine the incidence of hemolysis in patients implanted with LVAD, the mechanical complications detected in patients with hemolysis, and whether hemolysis can be used as a predictor of complications. Material and Methods: In this single-center, retrospective clinical research study, we evaluated 40 patients with HeartWare (HeartWare International, Inc., MA, USA) LVAD implants to assess the incidence of hemolysis and its association with mechanical complications. Hemolysis parameters, including lactate dehydrogenase (LDH), bilirubin, serum-free hemoglobin (sfHg), corrected reticulocyte count (CRC), and haptoglobin, were measured in venous blood samples obtained from patients attending cardiovascular outpatient clinics. Patients were divided into two groups( group 1:without hemolysis,n=32; group 2: with hemolysis,n=8) based on the presence or absence of hemolysis, and demographic data, comorbidities, and laboratory results were compared. The time elapsed after implantation of the patients was min: 90 days, max: 3147 days. Results: Hemolysis was detected in 20% (8 out of 40) of the patients included in the study. Patients with hemolysis demonstrated higher CRC, LDH, and total bilirubin levels(p<0,005), and lower haptoglobin levels compared to those without hemolysis(p<0,001). Intra-device thrombus was detected as a mechanical complication in 2 patients with hemolysis. One patient died and the other was discharged after medical treatment. Conclusion: Our findings suggest that routine monitoring of hemolysis parameters in LVAD recipients may aid in the early detection of mechanical complications, such as pump thrombosis, before symptomatic manifestation, thus potentially reducing mortality. Assessing multiple parameters, including LDH, bilirubin, sfHg, CRC, and haptoglobin, is crucial for accurate hemolysis diagnosis and its association with mechanical complications. It should be supported by large series of studies with longer and similar follow-up periods and a larger number of patients.

ECG abnormality and predictor of new-onset atrial fibrillation in hypertension and diabetes mellitus population: An observational analytic study from cardiovascular outpatient clinic at a National Cardiovascular Center in Indonesia.

Population-based studies have also found that diabetes mellitus (DM) and hypertension (HT) are independent risk factors for atrial fibrillation (AF). However, less is known about new-onset atrial fibrillation (NOAF) risk factors and its correlation with DM and HT. The aim of this study was to determine the prevalence and pattern of ECG abnormalities, and the predictor of NOAF in patients with HT and DM. This cross-sectional study was conducted at a tertiary hospital from May until December 2021. All medical record data from outpatients who had both diagnoses HT and DM were included in this study. Data from patients with unstable hemodynamics and lack of complete medical record data were excluded. Then, patient history, medical records, ECG, and laboratory information were reviewed. There were 162 patients included in this study. Arrhythmia was found in 14.2% of the population, with new-onset AF (NOAF) as the most common finding with 8.6% incidence, followed by PVC (3.1%) and PAC (2.5%). Bivariate analysis showed that valvular heart disease, random blood glucose, LVEF, and infection status were associated with a higher incidence of NOA. Model from multivariate logistic regression showed that valvular heart disease and random blood glucose level were independently correlated with NOAF (p = .009). It can be concluded that random blood glucose level at a certain point and valvular heart disease can be used as a risk predictor of NOAF in the hypertension population with concomitant DM.

The Relationship between Visceral Adiposity Form of Non-Alcoholic Fatty Liver Disease and Increased Epicardial Adipose Tissue Mass with Coronary Artery Disease

Abstract Background Cardiovascular disease is the largest cause of death in the world, and coronary artery disease (CAD) makes up the greatest proportion of those deaths that may enable more sensitive measures for risk stratification, or offer novel therapeutic targets for the prevention and treatment of coronary vascular disease. Aim of the Work to determine the association between visceral adiposity form of non-alcoholic fatty liver and increased Epicardial adipose tissue mass with coronary artery disease severity. Patients and Methods This study was conducted on fifty patients presented with signs and symptoms of coronary artery disease who were coming for elective coronary angiography at cardiovascular outpatient clinic in the internal medicine hospital, Ain Shams University from March 2018 to October 2018. Results In two patients with severe steatosis (Grade 3) the average thickness of long and short axes was detected 9.600 ± 0.141 mm. Average of 12 patients with no steatosis, Epicardial fat thickness was 6.323 ± 0.754 mm. In our study, Non critical coronary artery disease (below the 50% stenosis) was detected in eight patients (16 %). While critical coronary artery disease (Above the 50% stenosis) was detected in forty two patients (84%). According to the severity of coronary artery disease, in patients who do not have significant stenosis, EAT mean thickness was found 5.600± 0.400 mm measured. In patients with severe stenosis coronary artery disease, this value was measured as 7.857 ± 0.707 mm. In our study, Hypertension, diabetes mellitus and dyslipidemia (represented by LDL-c) were found to have statistically significant relations and correlation with EAT, but it was found that there was no statistically significant relationship between NAFLD fibrosis scoring system and FIB-4 with CAD. In this study, it was found a statistically significant relationship between the severity of NAFLD and CAD and a similar relationship between EAT and CAD. Conclusion Epicardial fat deposition is part of the same metabolic disorders associated with the development of fatty liver in individuals with insulin resistance and metabolic syndrome. High EAT may represent a marker of the severity of visceral adiposity as well as an independent predictor of cardiovascular and coronaries diseases risk.

The role of patient activation in self-care behaviours of Korean older adults with heart failure.

This study was aimed at investigating the level of patient activation, and its association with self-care behaviours in older people with heart failure. Cross-sectional secondary data analysis was conducted. We included a total of 182 Korean patients with heart failure who were aged ≥65 years for a cardiovascular outpatient clinic visit. Baseline characteristics, the Patient Activation Measure (PAM), health literacy, disease knowledge and self-care behaviours were collected via a self-administered questionnaire. The proportion of patient activation at Levels 1 and 2 was 22.5% and 14.3%, respectively. Highly activated patients had a high level of health literacy, disease knowledge and self-care behaviours. After adjusting for confounding factors, we observed that patient activation was the only statiscally significant predictor of self-care behaviours among older people with heart failure. Healthcare professionals should help patients take active roles in their self-care through a comprehensive needs assessment including health literacy and disease knowledge.

Factors affecting the quality of life of family caregivers of patients with heart failure: A cross-sectional study.

Heart failure is a chronic disease requiring lifetime self-management at home by patients, who often require additional support. However, the long-term nature of this self-management presents great challenges for both heart failure patients and their family caregivers. The role of family caregivers is critical, but little is known about the relationship between the burden, stress, depressive symptoms, and quality of life in the family caregivers of heart failure patients. We aimed to explore caregiver burden, stress, depressive symptoms, and quality of life in both patients with heart failure and their family caregivers and identify the factors associated with family caregivers’ quality of life.The sample included 120 participants (60 heart failure patients and 60 corresponding family caregivers) from cardiovascular outpatient clinics at 2 university-affiliated hospitals in South Korea from September 2018 to July 2019. The mean ages of the heart failure patients and their caregivers were 72.72 (SD = 12.73) and 57.03 (SD = 13.42) years, respectively. Caregiver burden (r = −0.601, P < .001) and caregiver depressive symptoms (r = -0.535, P < .001) were negatively correlated with the caregivers’ quality of life. The result of the hierarchical multiple regression analysis identified 3 significant factors related to the family caregivers’ quality of life: caregiver’s age (β = −0.257, P = .012), caregiver burden (β = −0.408, P = .002) and caregiver depressive symptoms (β = −0.298, P = .018), with overall explanatory power of 47.5%.It is necessary to develop practical strategies to improve family caregivers’ quality of life by alleviating their burden and depressive symptoms. Healthcare providers should be engaged with not only heart failure patients but also their family caregivers during the disease management process to improve patients’ outcomes.

Prevalence and factors associated with pre-frailty and frailty among Korean older adults with heart failure.

To describe the prevalence and associated factors of pre-frailty and frailty in older patients with heart failure. Secondary analysis of data collected across two cross-sectional surveys on self-care behaviours of patients with heart failure. We analysed the data of patients with heart failure who were 60 years or older (n=407) in cardiovascular outpatient clinics at two tertiary medical centres in South Korea between 2018 and 2019. Frailty was evaluated using the Korean version of the 5-item fatigue, resistance, ambulation, illnesses and loss of weight (FRAIL) scale. Frailty status was categorized as robust, pre-frail and frail. Multivariate multinomial logistic regression was used to examine the associations between sociodemographic, clinical characteristics and frailty status. In our sample, the prevalence of pre-frailty and frailty was 45.6% and 28.3% respectively. Patients aged 80 years or older had a higher prevalence of pre-frailty and frailty than those younger than 80 years. Advanced age and the worst category in the New York Heart Association (NYHA) functional classification were significantly associated with the risk of pre-frailty and frailty. Additionally, having more comorbid conditions was associated with an increased risk of frailty. Our study identified advanced age, the NYHA functional classification, and the number of comorbidities as the major characteristics associated with the risk of frailty in older patients with heart failure. The findings of this study highlight the prevalence and associated characteristics of pre-frailty and frailty in older adults with heart failure in South Korea. Most older adults with heart failure were either pre-frail or frail. Advanced age, the NYHA functional classification, and the number of comorbidities were the major characteristics associated with frailty risk. Our findings highlight the importance of incorporating frailty screening into routine assessments in older patients with heart failure.

Actual management costs of patients with non-valvular atrial fibrillation treated with percutaneous left atrial appendage closure or oral anticoagulation

AimsComparing actual management costs in patients with non-valvular atrial fibrillation (AF) treated with percutaneous left atrial appendage closure (LAAC) or OAC only. Methods and resultsPatients undergoing percutaneous LAAC and AF patients treated with OAC only were matched for gender, age, and diagnosis related groups (DRG) clinical complexity level (CCL). Costs for cardiovascular outpatient clinic visits and hospitalizations were derived from the actual reimbursement records.Between 1/2012 and 12/2016, 8478 patients were referred: 7801 (92%) managed with OAC and 677 (8%) with percutaneous LAAC. Matching resulted in 558 patients (279 per group) for final analysis. Age was 74.9 ± 7.5 years, 244 were female (43.7%), and DRG CCL was 1.8 ± 1.1.Annualized management cost before percutaneous LAAC was € 3110 (IQR: € 1281–8127). After 4.5 ± 1.4 years follow-up, annualized management cost was € 1297 (IQR: € 607–2735) in OAC patients and € 1013 (IQR: € 0–4770) in patients after percutaneous LAAC (p = 0.003). Percutaneous LAAC was the strongest independent determinant to reduce follow-up costs (B = −0.8; CI: −1.09 ̶̶̶̶̶ -0.6; p < 0.0001). Estimated 3-year survival was 92% in percutaneous LAAC and 90% in OAC patients (p = 0.7). ConclusionPercutaneous LAAC significantly reduces management costs. Management costs are significantly higher for patients treated with only OAC compared to patients after percutaneous LAAC. In spite of their complex comorbid profile, percutaneous LAAC patients show a follow-up survival rate similar to patients solely treated with OAC. Future studies are necessary to investigate the potential net economic and clinical benefit of percutaneous LAAC in patients treated with OAC only.

Psychosocial factors correlate with adherence to medications among cardiovascular outpatient clinics in Jordan.

Adherence to medications is a significant element of self-care behaviors for patients with cardiovascular diseases (CVDs). Non-adherence to cardiovascular medications is the major risk for poor outcomes following any cardiac event. However, there is a lack of studies that addressed medication adherence among patients with CVDs attending outpatient clinics in Arabic countries, including Jordan. Thus, this study purposed to assess the psychosocial factors (e.g. depression, anxiety, stress, social support and self-esteem) and their correlation with adherence to medications among patients with CVDs attending outpatient clinics in Jordan. A total of 395 Jordanian patients attending CVDs outpatient clinics at government, military and private healthcare facilities were recruited. Our study findings showed that 31.4% of the patients reported complete adherence to their medications. The proportion of psychological reactions reported by the participants was 72.1% for depressive symptoms, 62.6% for anxiety and 50.1% for stress; 79.7% had moderate and normal social support, and 44% had low self-esteem. Depression, anxiety and stress had a significant negative correlation with adherence to medications; however, self-esteem had a significant positive relationship with adherence to medications. In addition, depression, anxiety and stress were the main predictors of adherence to medications. Our findings might aid in paving the road for designing and developing strategies and interventions to increase adherence to medications and minimize these psychosocial problems among CVD patients in outpatient clinics.

Actual management costs of patients with non-valvular atrial fibrillation treated with percutaneous left atrial appendage closure or oral anticoagulation

Abstract Background Left atrial appendage closure (LAAC) is a safe and efficacious alternative to oral anticoagulation (OAC) therapy in patients with non-valvular atrial fibrillation (AF) who are at high risk for both stroke and bleeding. Data on cost-effectiveness of LAAO are limited and existing studies on the topic are based on simulation model approaches rather than on real-world costs. Purpose To compare actual management costs in patients with non-valvular AF treated with LAAC or OAC only. Methods Percutaneous LAAC was performed only in patients with at least one cerebral thromboembolic event, one major bleeding episode while under OAC, and with absolute contraindication to prolonged OAC. AF patients undergoing percutaneous LAAC were matched with AF patients treated with OAC only. Matching variables were gender, age, and Diagnosis Related Groups (DRG) clinical complexity level. Costs for cardiovascular outpatient clinic visits and hospitalizations were derived from the actual medical claims and reimbursement records. Data were prospectively collected and retrospectively analyzed. Results Between 1/2012 and 12/2016, 8478 patients with non-Valvular AF were referred to our institution: 7801 (92%) were managed with OAC only and 677 (8%) with LAAC. A total of 559 patients (279 per group) were matched. Mean age was 74.9±7.5 years, 244 were female (43.7%), and mean DRG clinical complexity level was 1.8±1.1. Median annualized management cost before LAAC was €3110 (IQR €1281–8127). Median hospitalization cost for LAAC was €9601 (IQR: €9393–10007). After a mean follow-up of 4.5±1.4 years, median annualized management cost was €1297 (€607–2735) in patients with sole OAC and €1013 (IQR €0–4770) in patients after LAAC (p=0.003). Undergoing LAAC was the strongest independent determinant to reduce follow-up management costs (linear regression: beta = −0.335; CI: −1.09 to −0.682; p&amp;lt;0.0001). Estimated 3-year survival was similar in the LAAC (92%) and OAC patients (90%) (p=0.7). Conclusion LAAC significantly reduces management costs of patients with non-valvular AF. In patients referred for percutaneous LAAC, the drastic reduction in management costs following LAAC justifies the procedural costs. In spite of their complex comorbid profile, LAAC patients show a follow-up survival rate similar to those of patients solely treated with OAC. Management costs of patients solely on OAC are significantly higher than management costs of patients after LAAC. Future studies are necessary to investigate the potential net economic and clinical benefit of LAAC in patients that are treated with OAC only. Funding Acknowledgement Type of funding sources: None.

Majmaah Bölgesi'nde (Suudi Arabistan Krallığı) Kardiyovasküler Hastalığı Olan Hastalarda Kardiyak Otonom Fonksiyon ile Metabolik Sendrom Arasındaki İlişki: Vaka Kontrol Gözlem Çalışması

Objective: Lacunae in literature persist regarding the mechanisms connected with the progression from metabolic syndrome (MetS) to Type 2 diabetes and cardiovascular disease (CVD). To validate heart rate variability (HRV), as a tool for progression of CVD in patients visiting cardiovascular outpatient clinic. Material and Methods: This crosssectional study involved screening of 126 patients for the presence of one or more cardiometabolic risk factors and followed with HRV measurement after categorizing them as MetS+ or control MetS-. Results: Time domain analysis showed a significant reduction between male and female of MetS- and MetS+ While frequency domain analysis in MetS+ male showed no difference, MetS+ female showed significant difference in TP and HF indices. With increasing number of metabolic components, the MetS+ males exhibited significant decrease in the time domain and increase in frequency domain indices of HRV. Body mass index (BMI), waist circumference (WC), high-density lipoprotein (HDL), and triglyceride (TG) were associated with time and frequency domain of HRV among MetS+ and MetS- males and females. Low density lipoprotein (LDL) was a significant predictor of SDNN, RRSSD, and NN50 in patients with MetS+ while HDL was a significant predictor of Standard deviation of normal-to-normal intervals (SDNN) and pNN50. BMI was significant predictor of SDNN and pNN50 in MetS- patients and NN50 in MetS+ patients. In MetS+, the significant predictor of HF was WC, TG, HDL and LDL and that of LF were TG and LDL while in MetS-, WC was significant predictor of LF and HDL of LF/HF. Conclusion: MetS+ females showed lower vagal activity and decreased sympathetic predominance as compared to MetS males suggesting greater cardiovascular risk.

Effect of psychosocial factors and heart ate variability on blood pressure control in patient with primary hypertension:A path analysis

Abstract Background Hypertension (HTN) is one of the major factors driving the global burden of cardiovascular diseases. About 40% of the adults are affected by elevated blood pressure around the world. The etiology of HTN is multifactorial, including psychological distress, especially symptoms of anxiety and depression. A few meta-analyses and longitudinal studies have reported an association between symptoms of anxiety, depression and HTN. Social support is an important factor in the regulation of emotions in HTN patients. The autonomic nervous system (ANS) plays an important role in the homeostatic control of the cardiovascular system. The measurement of heart rate variability (HRV) is used to evaluate ANS regulation in clinical research.The HRV is also a predictor of cardiovascular-cause events and mortality. Previous studies have identified the association of cardiovascular diseases with social support, anxiety, and depression. Some recent studies have also evaluated the relationship between HRV and cardiovascular diseases. However, very few studies have investigated the association of psychosocial factors, HRV, and blood pressure in patients with HTN. Purpose The purpose of this study was to evaluate the effect of psychosocial factors including social support, symptoms of anxiety/depressive, and heart rate variability on mean arterial blood pressures in patients with primary hypertension. Methods A cross-sectional descriptive and correlative study was performed. Participants were recruited by convenience sampling from the Cardiovascular Outpatient Clinic at a Medical Center. Data were collected using structured questionnaires, including the Social Support and Hospital Anxiety and Depression Scales. While heart rate variability was measured by a handheld limb lead electrocardiogram recorder device, blood pressure was measured by an automatic sphygmomanometer. Data were analyzed by the structural equation path analysis by the IBM SPSS Amos 21.0 statistical software packages. Results This study included 301 patients with primary hypertension. The scores of the Social Support Scale had a significantly direct effect on the scores of Hospital Anxiety and Depression Scale. The Hospital Anxiety and Depression Scale scores had a significantly direct effect on the heart rate variability. The low frequency/ high-frequency ratio of heart rate variability had a significantly direct effect on the mean arterial blood pressures. The path model including all variables explained 45% variance in the mean arterial blood pressures and had good fit indices. Conclusion Findings from our research highlight the significance of how psychosocial factors can affect the autonomic nervous system and blood pressure control of patients with primary hypertension. These findings can aid in developing an intervention program for blood pressure management in future. Funding Acknowledgement Type of funding source: None

Serum Apelin Levels and Ascending Aortic Aneurysm in Adults

Apelin is a peptide isolated from bovine stomach and has vasodilator and inotropic activities. The aim of this study was to confirm the relationship between serum apelin levels and ascending aortic dilatation in adult patients. This study included 39 patients with ascending aortic aneurysm who applied to the cardiovascular surgery outpatient clinic between 1 June 2019 and 31 August 2019 and 50 healthy volunteers. Serum apelin and serum apelin receptor levels were measured with ELISA method. Serum apelin levels were lower in patients with aortic aneurysm compared to the control group, while serum apelin receptor levels were higher. These findings may show that serum apelin and apelin receptor levels may be a potential biomarker for aortic aneurysm.

Association of poor sleep quality with risk factors after coronary artery bypass graft surgery—A prospective cohort study

Fragmented sleep is a daunting experience and a common health problem with high prevalence among patients 3months after coronary artery bypass grafting (CABG). However, the potential predictors on poor seep quality remains unexplored. The main purpose of this study was to determine the predictors of poor sleep quality among patients 3months after CABG. A prospective cohort study is a part of the randomized controlled trial between 2012 and 2013 in which 400 adult patients undergoing elective CABG were being randomly sampled as per the inclusion criteria followed up at 3months after CABG surgery in the cardiovascular outpatient clinic of a tertiary-care hospital. The study was conducted according to the Declaration of Helsinki and was approved by the institutional ethical committee. All participants gave written informed consent on having received detailed information on the study. Demographic and clinical data were obtained from medical records at the time of CABG. The data on sleep quality were collected by using the Pittsburgh Sleep Quality Index and state anxiety was evaluated utilizing state-trait anxiety inventory (STAI-YI fo3rm). Multivariable logistic regression examined the association between the postoperative poor sleep quality and clinical, preoperative state anxiety, and angina. The significant variables are chosen based on the P-value associated with the significant level of model that lies on α=0.05. Logit determination and the correlation between the variables are also discussed for further analysis. A total of 187 patients (mean age 55.6±12.05years) completed the questionnaire. Most patients (78%) reported poor sleep quality (4.23±1.24) (PQSI score of less than 5). There was a strong relationship between PQSI and state anxiety. The higher state anxiety among 68% of patients with the mean score (53.51±9.55) had 6.42 (95% CI 3.04-9.61) times the odds of being classified as high risk for sleep disturbance. There are 3 factors that most significant of the 8 factors tested were identified as having influence significantly on the poor sleep quality. These factors are diabetes (OR 1.186, 95% CI 1.016-1.097, P>.01), body mass index>30kg/m2 (OR 2.36, 95% CI 1.041-1.172, P>.05), sedentary lifestyle (OR 1.091, 95% CI 1.016-1.159, P>.01), and preoperative state anxiety (OR 1.186, 95% CI 1.074-1.115, P>.01). Even though the body mass index>30kg/m2, sedentary lifestyle, and diabetes were significantly associated with sleep quality, the only factor with more significantly related to poor sleep quality was preoperative state anxiety which is the strong predictor of poor sleep quality. Hence, early recognition of predictors and careful management of poor sleep quality is warranted.

Plasma Xanthine Oxidoreductase (XOR) Activity in Cardiovascular Disease Outpatients.

Background: The mechanisms of the increased plasma xanthine oxidoreductase (XOR) activity in outpatients with cardiovascular disease were unclear.Methods and Results: A total of 372 outpatients were screened, and 301 outpatients with cardiovascular disease were prospectively analyzed. Blood samples were collected from patients who visited a daily cardiovascular outpatient clinic. Patients with diabetes mellitus (DM) were significantly more likely to be classified into the high-XOR group (≥100 pg/h/mL; 50%) than the low-XOR group (<100 pmol/h/mL; 28.7%). On multivariate logistic regression analysis, DM (OR, 2.683; 95% CI: 1.441–4.996) was independently associated with high plasma XOR activity in all cohorts. In the diabetic cardiovascular disease patients (n=100), median body mass index (BMI) in the high-XOR group (28.0 kg/m2; IQR, 25.2–29.4 kg/m2, n=32) was significantly higher than in the low-XOR group (23.6 kg/m2; IQR, 21.2–25.7 kg/m2, n=68), and BMI was independently associated with high plasma XOR activity (OR, 1.340; 95% CI: 1.149–1.540). Plasma hydrogen peroxide was significantly higher in DM patients with high plasma XOR activity and obesity (>22 kg/m2) than in other patients.Conclusions: DM with obesity is one of the mechanisms of XOR enhancement in cardiovascular disease. The increase of XOR is a possible pathway for the production of reactive oxygen species in obese cardiovascular disease patients with DM.

The Correlation between p53 Serum Levels and Vascular Age was Measured by Carotid Intima Media Thickness (CIMT) in Patients with Moderate Cardiovascular Risk Factors

Protein p53 has an important role in atherosclerosis plaque as part of senescence cell vascular. Increased vascular aging process is characterized by several parameters, one of which is an increase in carotid intima media thickness (CIMT). CIMT is one of the non-invasive methods that can determine vascular age, which is a safe, fast and inexpensive method of assessing atherosclerosis. This study was a correlational study conducted at cardiovascular outpatient clinic from August until November 2015. Serum p53 levels were measured by human p53 ELISA kit. CIMT is measured by B-mode ultrasound. The CIMT value was based on the normogram of the Atheosclerosis Risk in Communities Study. Spearman rank test was used to analyze the relationship between serum p53 and vascular age. There were 19 men and 19 women in the subject of this study. The average vascular age is 54.34 + 8.5 years. Serum p53 levels were positively correlated with vascular age in the subject group of this study (p <0.001; r = 0.58). There is a positive, strong and significant correlation between serum p53 and vascular age levels determined by CIMT in patients with moderate cardiovascular risk factors.