Chronic Cardiovascular Conditions Research Articles

Potential Impact of SARS-CoV-2 Infection in HIV-positive Patients in South Africa

ABSTRACTCoronaviruses are important causes of infection in both humans and animals. While in the past they were considered to be relatively harmless respiratory pathogens, outbreaks of infection with severe acute respiratory syndrome (SARS), Middle East respiratory syndrome, and currently SARS-CoV-2, have confirmed how serious these pathogens can be in respiratory tract infections. Certain conditions and underlying comorbidities are known to be risk factors for SARS-CoV-2 infection, and for associated severe disease, including older age, underlying chronic cardiovascular and respiratory conditions and diabetes mellitus. There are a number of additional conditions and comorbidities that are suspected as being important risk factors, but for which hard evidence is currently lacking. This includes underlying human immunodeficiency virus infection, which represents the major focus of this current survey of the scientific literature.

Heart failure treatment and the art of medical decision making.

Heart failure treatment and the art of medical decision making.

Aggregation of Asian-American subgroups masks meaningful differences in health and health risks among Asian ethnicities: an electronic health record based cohort study

BackgroundFew large cohort studies have examined the prevalence of diabetes mellitus (DM), hypertension (HTN), coronary artery disease (CAD), obesity, and smoking among middle-aged and older adults in the major Asian-American ethnic groups and Native Hawaiian/Pacific Islanders (PIs). The aim of this study was to evaluate how prevalence of these conditions and risk factors differs across Asian-American and PI ethnic groups and compares with an aggregated All Asian-American racial group.MethodsThis study used a cohort of 1.4 million adults aged 45 to 84 who were Kaiser Permanente Northern California health plan members during 2016. The cohort included approximately 274,910 Asian-Americans (Chinese, Filipino, Japanese, Korean, Southeast Asian, South Asian, other), 8450 PIs, 795,080 non-Hispanic whites, 107,200 blacks, and 210,050 Latinos. We used electronic health record data to produce age-standardized prevalence estimates of DM, HTN, CAD, obesity (using standard and Asian thresholds), and smoking for men and women in all racial/ethnic subgroups and compared these subgroups to an aggregated All Asian-American racial group and to whites, blacks, and Latinos.ResultsWe found large differences in health burden across Asian-American ethnic subgroups. For both sexes, there were 16 and > 22 percentage point differences between the lowest and highest prevalence of DM and HTN, respectively. Obesity prevalence among Asian subgroups (based on an Asian BMI ≥ 27.5 kg/m2 threshold) ranged from 14 to 39% among women and 21 to 45% among men. Prevalence of smoking ranged from 1 to 4% among women and 5 to 14% among men. Across all conditions and risk factors, prevalence estimates for Asian-American and PI ethnic groups significantly differed from those for the All Asian-American group. In general, Filipinos and PIs had greater health burden than All Asians, with prevalence estimates approaching those of blacks.ConclusionsIn a population of middle-aged and older adult Northern California health plan members, we found substantive differences in prevalence of chronic cardiovascular conditions, obesity, and smoking across Asian-American ethnic groups and between Asian-American ethnic groups and an aggregated All Asian racial group. Our study confirms that reporting statistics for an aggregated Asian-American racial group masks meaningful differences in Asian-American ethnic group health.

New treatments for hyperkalaemia: clinical use in cardiology.

Hyperkalaemia causes significant burden, and even mild hyperkalaemia has been independently associated with increased morbidity and mortality. Patients with chronic disease states, such as heart failure, hypertension, chronic kidney disease and diabetes mellitus, are increasingly susceptible to the development of hyperkalaemia. Options for management of hyperkalaemia had mainly been limited to short-term, temporizing methods with focus on rapid achievement of normokalaemia. Until recently, there was a lack of safe, efficacious and well-tolerated therapies for long-term management. Two novel potassium binders, patiromer and sodium zirconium cyclosilicate, have recently been approved by the US Food and Drug Administration for the management of hyperkalaemia. This review discusses these potassium binders with focus largely on the clinical implications of these agents in patients with chronic cardiovascular conditions.

TREM-1; Is It a Pivotal Target for Cardiovascular Diseases?

Cardiovascular diseases (CVDs) are as menacing as ever and still continue to kill adults worldwide, notwithstanding tremendous efforts to decrease their consequent mortality and morbidity. Lately, a growing body of research indicated that inflammation plays a pivotal role in the pathogenesis and complications of CVDs. A receptor of the immunoglobulin superfamily, triggering receptors expressed on myeloid cells-1 (TREM-1) was shown to induce and amplify the inflammation in both acute and chronic disease’ pathogenesis and progression, which hence makes it one of the most important complication factors of CVDs. Thus, studies endeavored to investigate the role played by TREM-1 in CVDs with respect to their etiologies, complications, and possible therapeutics. We examined here, for the first time, the most relevant studies regarding TREM-1 involvement in CVDs. We critically analyzed and summarized our findings and made some suggestions for furtherance of the investigations with the aim to utilize TREM-1 and its pathways for diagnostic, management, and prognosis of CVDs. Overall, TREM-1 was found to be involved in the pathogenesis of acute and chronic cardiovascular conditions, such as acute myocardial infarction (AMI) and atherosclerosis. Although most therapeutic approaches are yet to be elucidated, our present research outcome displays a promising future to utilizing the TREM-1 pathway as a potential target for understanding and managing CVDs.

Seasonality and clinical impact of human parainfluenza viruses.

BackgroundWidespread availability of rapid diagnostic testing for respiratory viruses allows more in‐depth studies of human parainfluenza viruses (HPIV).ObjectivesThis study aimed to assess seasonality of HPIV types 1‐4, clinical outcomes by HPIV type, and risk factors for illness severity.Patients/MethodsThis retrospective study was performed from January 2013 to December 2015 in children and adults with HPIV, detected by multiplex reverse transcription polymerase chain reaction, participating in a community surveillance study of acute respiratory infections (ARIs) in New York City and patients admitted to a tertiary care center in the same neighborhood. Seasonality trends by HPIV type were compared between the community and hospital groups. The associations between HPIV type, demographics, clinical characteristics, and illness severity were assessed.ResultsHPIV was detected in 69 (4%) of 1753 community surveillance participants (median age 9.2 years) and 680 hospitalized patients (median age 6.8 years). Seasonality for HPIV types 1‐3 agreed with previously described patterns; HPIV‐4 occurred annually in late summer and fall. In the community cohort, 22 (32%) participants sought medical care, 9 (13%) reported antibiotic use, and 20 (29%) reported ≥1 day of missed work or school. Among hospitalized patients, 24% had ≥4 chronic conditions. Multivariable ordinal logistic regression demonstrated that increased severity of illness was significantly associated with HPIV‐4 and chronic cardiovascular and respiratory conditions in children and with age ≥65 years and chronic respiratory conditions in adults.ConclusionsHPIV‐4 presented late summer and early fall annually and was associated with increased severity of illness in hospitalized children.

Highlights From the Circulation Family of Journals

Highlights From the <i>Circulation</i> Family of Journals

Who you are and where you live can determine how long you live: What nurses need to know about cardiovascular disease among low‐income urban‐dwelling minority communities

Who you are and where you live can determine how long you live: What nurses need to know about cardiovascular disease among low‐income urban‐dwelling minority communities

Cluster-Randomized Trial to Evaluate a Centralized Clinical Pharmacy Service in Private Family Medicine Offices.

The use of clinical pharmacists in primary care has improved the control of several chronic cardiovascular conditions. However, many private physician practices lack the resources to implement team-based care with pharmacists. The purpose of this study was to evaluate whether a centralized, remote, clinical pharmacy service could improve guideline adherence and secondary measures of cardiovascular risk in primary care offices in rural and small communities. This study was a prospective trial in 12 family medicine offices cluster randomized to either the intervention or usual care. The intervention was delivered for 12 months, and subjects had research visits at baseline and 12 months. The primary outcome was adherence to guidelines, and secondary outcomes included changes in key cardiovascular risk factors and preventative health measures. We enrolled 302 subjects. There was no improvement in the Guideline Advantage score from baseline to 12 months in the control group (64.7% versus 63.1%, respectively; P=0.21). There was a statistically significant improvement in the intervention group from 63.3% at baseline to 67.8% at 12 months (P=0.02). The estimated benefit of the intervention was 5.0%±2.4% (95% confidence interval=-0.5% to 10.4%; P=0.07). Several criteria were significantly better for intervention subjects, including appropriate statin therapy (P<0.001), body mass index, screening (P<0.001), and alcohol screening (P<0.001). Only 13.7% of subjects with diabetes mellitus had hemoglobin A1c at goal at baseline, and this increased to 30.8% and 21.0% in the intervention and control group, respectively, at 12 months (P=0.10). The centralized, remote pharmacist intervention was successfully implemented. The improvements in outcomes were modest, in part because of higher than expected baseline guideline adherence. Future studies of this model should focus on patients with uncontrolled conditions at high risk for cardiovascular events. URL: https://www.clinicaltrials.gov. Unique identifier: NCT 01983813.

Prevalence of Chronic and Pregnancy-Induced Cardiovascular Conditions in Severe Maternal morbidity in Texas [24B

INTRODUCTION: In 2011-2012, the three leading causes of maternal mortality in Texas were cardiac events, drug overdose, and hypertension/eclampsia, with two out of the three being cardiovascular-related conditions. While chronic conditions likely contribute to mortality, severe maternal morbidity (SMM) metrics only include eclampsia and do not include chronic cardiovascular conditions such as preexisting hypertension. To better understand the contribution of both pregnancy-induced and chronic cardiovascular conditions to SMM, the prevalence of comorbid cardiovascular conditions among women with SMM was assessed. METHODS: Delivery-related hospitalizations between 2011-2014 were classified as SMM, based on the CDC’s coding scheme. Cardiovascular comorbidities among SMM were classified using the obstetric comorbidity coding scheme identified by Bateman et al (2013). Prevalence was assessed by age to examine whether older women with SMM had higher prevalence of these comorbidities. RESULTS: SMM prevalence remained consistent between 2011 and 2014 (19.6-19.8 per 1,000 deliveries, p=0.57). Overall, SMM showed a quadratic relationship with age, with the youngest and oldest age groups having the highest prevalence (p&lt;0.01). Among comorbidities assessed in SMM, the youngest and oldest age groups had the highest prevalence of severe preeclampsia/eclampsia. However, the prevalence of preexisting hypertension increased linearly with age. CONCLUSION: Older women with SMM were comorbid for both pregnancy-induced and chronic cardiovascular conditions, whereas younger women had pregnancy-induced conditions. This finding suggests a need to assess the role of chronic cardiovascular conditions in SMM, especially among older women. Results also suggest that the narrowly defined SMM metric may underestimate the contribution of chronic cardiovascular conditions to severe maternal morbidity.

Obesity, Metabolic Syndrome, and Musculoskeletal Disease: Common Inflammatory Pathways Suggest a Central Role for Loss of Muscle Integrity.

Inflammation can arise in response to a variety of stimuli, including infectious agents, tissue injury, autoimmune diseases, and obesity. Some of these responses are acute and resolve, while others become chronic and exert a sustained impact on the host, systemically, or locally. Obesity is now recognized as a chronic low-grade, systemic inflammatory state that predisposes to other chronic conditions including metabolic syndrome (MetS). Although obesity has received considerable attention regarding its pathophysiological link to chronic cardiovascular conditions and type 2 diabetes, the musculoskeletal (MSK) complications (i.e., muscle, bone, tendon, and joints) that result from obesity-associated metabolic disturbances are less frequently interrogated. As musculoskeletal diseases can lead to the worsening of MetS, this underscores the imminent need to understand the cause and effect relations between the two, and the convergence between inflammatory pathways that contribute to MSK damage. Muscle mass is a key predictor of longevity in older adults, and obesity-induced sarcopenia is a significant risk factor for adverse health outcomes. Muscle is highly plastic, undergoes regular remodeling, and is responsible for the majority of total body glucose utilization, which when impaired leads to insulin resistance. Furthermore, impaired muscle integrity, defined as persistent muscle loss, intramuscular lipid accumulation, or connective tissue deposition, is a hallmark of metabolic dysfunction. In fact, many common inflammatory pathways have been implicated in the pathogenesis of the interrelated tissues of the musculoskeletal system (e.g., tendinopathy, osteoporosis, and osteoarthritis). Despite these similarities, these diseases are rarely evaluated in a comprehensive manner. The aim of this review is to summarize the common pathways that lead to musculoskeletal damage and disease that result from and contribute to MetS. We propose the overarching hypothesis that there is a central role for muscle damage with chronic exposure to an obesity-inducing diet. The inflammatory consequence of diet and muscle dysregulation can result in dysregulated tissue repair and an imbalance toward negative adaptation, resulting in regulatory failure and other musculoskeletal tissue damage. The commonalities support the conclusion that musculoskeletal pathology with MetS should be evaluated in a comprehensive and integrated manner to understand risk for other MSK-related conditions. Implications for conservative management strategies to regulate MetS are discussed, as are future research opportunities.

Awareness, treatment, and control of dyslipidemia in rural South Africa: The HAALSI (Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa) study.

Dyslipidemia is a primary driver for chronic cardiovascular conditions and there is no comprehensive literature about its management in South Africa. The objective of this study was to assess the prevalence, awareness, treatment, and control of dyslipidemia in rural South Africa and how they are impacted by different behaviors and non-modifiable factors. To fulfill this objective we recruited for this cohort study adults aged ≥40 years residing in the Agincourt sub-district of Mpumalanga Province. Data collection included socioeconomic and clinical data, anthropometric measures, blood pressure (BP), HIV-status, point-of-care glucose and lipid levels. Framingham CVD Risk Score was ascribed to patients based upon categories for 10 year cardiovascular risk of low (<3%), moderate (≥3% and <15%), high (≥15% and <30%), and very high (≥30%).LDL cholesterol control by risk category was defined according to South African Guidelines. Multivariable logistic regression models were built to identify factors that were significantly associated with dyslipidemia and awareness of dyslipidemia From 5,059 respondents a total of 4247 subjects (83.9%) had their cholesterol levels measured and were included in our analysis. Overall, 67.3% (2860) of these met criteria for dyslipidemia, only 30 (1.05%) were aware of their condition, and only 21 subjects (0.73%) were on treatment. The majority have abnormalities in triglycerides (59.3%). As cardiovascular risk increased the rates of lipid control according to LDL level dropped. Multivariate logistic regression analyses showed that being overweight was predictive of dyslipidemia (OR 1.76; 95%CI 1.51–2.05, p<0.001) and dyslipidemia awareness (OR 2.58; 95%CI 1.19–5.58; p = 0.017). In conclusion, the very low awareness and treatment of dyslipidemia in this cohort indicate a greater need for systematic screening and education within the population and demonstrate that there are multiple opportunities to allay this burden.

Update on Development of a national Framework and Implementation plan for Self management Support for Chronic conditions: COPD, Asthma, Diabetes and Cardiovascular disease

Introduction: An Irish national framework for self management support (SMS) for chronic conditions ( COPD, Asthma, Diabetes & Cardiovascular disease) has been developed over the last two years and implementation will start in 2017. The initial steps in the development of the framework were presented at the IFIC conference in Barcelona in 2016. Since then a national consultation was carried out on the draft framework, and further work done to incorporate the findings of consultation into the final framework, and to develop an implementation plan. This presentation will give an overview of the key findings from the national consultation; changes made to the framework; and outline the planned Implementation actions over the next 3 years. Description of policy context and objective: Ireland, like other developed countries, needs to re-orientate its health services, in light of its ageing population and chronic disease prevalence, in order to ensure the sustainability of health services into the future. While national guidelines recommend SMS for specific chronic conditions, this has not been implemented widely despite patient views that it should be a priority. Healthy Ireland: A Framework for Improved Health and Wellbeing 2013 – 2025 (DOH 2013) recognises the need to implement a model for the prevention and management of chronic illnesses, empowering people and communities, with an emphasis on partnership and cross-sectoral work to increase the proportion of people who are healthy at all stages of life. Arising from this, the HSE committed to finalising a framework and implementation plan for SMS for COPD, Asthma, Diabetes and Cardiovascular disease in 2016. Targeted population: People living with chronic conditions, initially COPD, Asthma, Diabetes and Cardiovascular conditions Highlights: the consultation on the draft framework gave rise to themes in relation to the content of the framework, communication issues, and implementation issues. Themes included: a high level of support for provision of SMS among patients, staff and HSE senior management the need for a ‘patient friendly’ version of the framework to help everyone to understand the concept of SMS and what should be provided Lack of resources in primary care were identified as a major barrier: this approach requires a high level of collaboration across the boundaries of primary care, community health organisations and hospital groups Implementation will require coordination at national and local level, training of healthcare professionals, information provision, communications plan, increased provision, access and standardisation of disease specific programmes; provision of peer and social support; a whole system approach Comments on transferability: While some areas have developed SMS services of varying types, there is inconsistent and fragmented provision - the national framework needs to guide development and coordination at national and local level. Conclusions: Main points from the consultation findings, the framework - a whole system model, and planned implementation actions over a 3 year period will be presented.

BASE RATES OF IMPAIRED SCORES ARGUE AGAINST CORRECTION FOR MEDICAL CONDITIONS WITHIN A BRIEF NEUROPSYCHOLOGICAL BATTERY

Normative data are usually created by making demographic adjustments based on correlations between single neuropsychological tests with demographic variables such as age and education. However, this traditional approach has some limitations. For example, it does not detail the implications for clinical practice such as likelihood of misclassification of cognitive impairment. It also does not elucidate the impact on decision making when using a neuropsychological battery. We hypothesize that baserates analyses, particularly, differential baserates of impaired scores between theoretical and actual baserates, would be better suited to create demographic adjustments within normative data. Differential baserates empirically detail the potential clinical implications of failing to create an appropriate normative group. Thus the aim of the present study is to explore whether adjustments for age and medical conditions are warranted based on differential baserates of spuriously impaired scores. The present study uses telephone-administered data collected from over 20,000 participants of the Canadian Longitudinal Study on Aging (CLSA). The CLSA has recruited a large national sample of approximately 50,000 French- and English-speaking men and women between the ages of 45 and 85 across 10 Canadian provinces; over 20,000 responded through telephone interview and 30,000 to an in-home interview and physical assessments at a data collection site. Differential baserates are calculated using the results of a short neuropsychological battery administered by telephone to a neurologically healthy sample (but only the English-speaking sub-sample is used in the present research). Theoretical baserates underestimate the frequency of impaired scores in older adults, providing an evidence base for the creation of age corrected normative data. Interestingly, several medical conditions such as cancer, chronic obstructive pulmonary disease, cardiovascular (e.g., high blood pressure, angina, acute myocardial infarction), hormonal (e.g., hypo- and hyperthyroidism) and metabolic (e.g., diabetes) conditions are not associated to differential baserates of impaired scores. Despite a small magnitude correlation between number of medical conditions and each neuropsychological variable, normative adjustments for number of medical conditions does not appear warranted.

Integrated care in atrial fibrillation: a systematic review and meta-analysis

ObjectiveAtrial fibrillation (AF) is an emerging global epidemic associated with significant morbidity and mortality. Whilst other chronic cardiovascular conditions have demonstrated enhanced patient outcomes from coordinated systems of care, the...

Improving stroke prevention therapy for patients with atrial fibrillation in primary care: protocol for a pragmatic, cluster-randomized trial.

BackgroundThe prevalence of atrial fibrillation (AF) is growing as the population ages, and at least 15% of ischemic strokes are attributed to AF. However, many high-risk AF patients are not offered guideline-recommended stroke prevention therapy due to a variety of system, provider, and patient-level barriers.MethodsWe will conduct a pragmatic, cluster-randomized controlled trial randomizing primary care clinics to test a “toolkit” of quality improvement interventions in primary care. In keeping with the recommendations of the chronic care model to simultaneously activate patients and facilitate proactive care by providers, the toolkit includes provider-focused strategies (education, audit and feedback, electronic decision support, and reminders) plus patient-directed strategies (educational letters and reminders). The trial will include two feedback cycles at baseline and approximately 6 months and a final data collection at approximately 12 months. The study will be powered to show a difference of 10% in the primary outcome of proportion of patients receiving guideline-recommended stroke prevention therapy. Analysis will follow the intention-to-treat principle and will be blind to treatment allocation. Unit of analysis will be the patient; models will use generalized estimating equations to account for clustering at the clinical level.DiscussionStroke prevention therapy using anticoagulation in patients with AF is known to reduce strokes by two thirds or more in clinical trials, but most studies indicate under-use of this treatment in real-world practice. If the toolkit successfully improves care for patients with AF, stakeholders will be engaged to facilitate broader application to maximize the potential to improve patient outcomes. The intervention toolkit tested in this project could also provide a model to improve quality of care for other chronic cardiovascular conditions managed in primary care.Trial registrationClinicalTrials.gov (NCT01927445). Registered August 14, 2014 at https://clinicaltrials.gov/.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0523-2) contains supplementary material, which is available to authorized users.

The economic burden of chronic non-communicable diseases in rural Malawi: an observational study.

BackgroundEvidence from population-based studies on the economic burden imposed by chronic non-communicable diseases (CNCDs) is still sparse in Sub-Saharan Africa. Our study aimed to fill this existing gap in knowledge by estimating both the household direct, indirect, and total costs incurred due to CNCDs and the economic burden households bear as a result of these costs in Malawi.MethodsThe study used data from the first round of a longitudinal household health survey conducted in 2012 in three rural districts in Malawi. A cost-of-illness method was applied to estimate the economic burden of CNCDs. Indicators of catastrophic spending and impoverishment were used to estimate the economic burden imposed by CNCDs on households.ResultsA total 475 out of 5643 interviewed individuals reported suffering from CNCDs. Mean total costs of all reported CNCDs were 1,040.82 MWK, of which 56.8 % was contributed by direct costs. Individuals affected by chronic cardiovascular conditions and chronic neuropsychiatric conditions bore the highest levels of direct, indirect, and total costs. Using a threshold of 10 % of household non-food expenditure, 21.3 % of all households with at least one household member reporting a CNCD and seeking care for such a condition incurred catastrophic spending due to CNCDs. The poorest households were more likely to incur catastrophic spending due to CNCDs. An additional 1.7 % of households reporting a CNCD fell under the international poverty line once considering direct costs due to CNCDs.ConclusionOur study showed that the economic burden of CNCDs is high, causes catastrophic spending, and aggravates poverty in rural Malawi, a country where in principle basic care for CNCDs should be offered free of charge at point of use through the provision of an Essential Health Package (EHP). Our findings further indicated that particularly high direct, indirect, and total costs were linked to specific diagnoses, although costs were high even for conditions targeted by the EHP. Our findings point at clear gaps in coverage in the current Malawian health system and call for further investments to ensure adequate affordable care for people suffering from CNCDs.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1716-8) contains supplementary material, which is available to authorized users.

Uric Acid and Neurocognitive Function in Survivors of Childhood Acute Lymphoblastic Leukemia Treated with Chemotherapy Only.

Hyperuricemia is implicated in cardiovascular and cerebrovascular diseases. This study evaluated associations between uric acid (UA), cardiovascular health, and neurocognitive function in adolescent and adult survivors of childhood acute lymphoblastic leukemia treated with chemotherapy only. 126 adolescent [mean (SD) age 14.6 (5.0); 7.8 (1.7) years postdiagnosis] and 226 adult survivors [age 25.4 (4.2) years; 18.1 (4.4) years postdiagnosis] completed comprehensive neurocognitive testing. Concurrent UA measurements were conducted for both groups. For adult survivors, cardiovascular risk factors were assessed, and UA measurements during adolescence [12.3 (4.0) years before neurocognitive testing] were also collected. UA levels were categorized into quartiles for age- and gender-based ranking, and associations with neurocognitive outcomes were examined. Survivors demonstrated worse attention, processing speed, and executive functions than population norms (P values < 0.05). Adolescent survivors with elevated UA had poorer attention (P = 0.04), visual-processing speed (P = 0.03), and cognitive flexibility (P = 0.02). UA was not associated with neurocognitive outcomes in adult survivors. Adult survivors developed dyslipidemia (46%), hypertension (32%), and abdominal obesity (26%), and high UA during adolescence was associated with these cardiovascular risk factors as adults (all P values < 0.01). Fine-motor processing speed was slower in adult survivors with dyslipidemia (P = 0.04) and abdominal obesity (P = 0.04). Poorer attention was marginally associated with hypertension (P = 0.06). Elevated UA is associated with neurocognitive performance in adolescent survivors. In adult survivors, relative elevation of UA during adolescence was predictive of cardiovascular health, which was associated with poorer neurocognitive outcomes. Future studies should evaluate the mediating role of chronic cardiovascular health conditions between elevated UA and subsequent neurocognitive impairment in survivors. Cancer Epidemiol Biomarkers Prev; 25(8); 1259-67. ©2016 AACR.

Cumulative burden of cardiovascular morbidity in paediatric, adolescent, and young adult survivors of Hodgkin's lymphoma: an analysis from the St Jude Lifetime Cohort Study

BackgroundThe magnitude of cardiovascular morbidity among survivors of pediatric, adolescent, and young adult Hodgkin lymphoma is not known. Using medically ascertained data, we applied the cumulative burden metric to compare chronic cardiovascular health conditions among Hodgkin survivors and general population controls.MethodsAmong 670 survivors treated at St. Jude Children’s Research Hospital, who survived ≥10 years and became 18 years old, 348 were clinically assessed in the St. Jude Lifetime Cohort Study (SJLIFE). Age-sex-frequency-matched SJLIFE community-controls (n=272) were used for comparison. All SJLIFE participants underwent evaluation for 22 chronic cardiovascular health conditions. Direct assessments, combined with retrospective clinical reviews, were used to assign severity to conditions using a modified Common Terminology Criteria of Adverse Events (CTCAE) grading schema. Occurrences and CTCAE-grades of the conditions for 322 eligible non-SJLIFE participants were accounted for by multiple imputation. The mean cumulative count (treating death as a competing risk) was used to estimate cumulative burden.FindingsAt 50 years of age, the cumulative incidence of survivors experiencing at least one grade 3-5 cardiovascular condition was 45.5%. The survivor cohort experienced, on average, 430·6 (95% confidence interval, 380·7-480·6) grade 1-5 and 100·8 (77·3-124·3) grade 3-5 cardiovascular conditions per 100 survivors. At age 50, the grade 1-5 and 3-5 cumulative burdens of community-controls were appreciably lower at 227·4/100 (192·7-267·5) and 17·0/100 (8·4-27·5), respectively. Myocardial infarction and structural heart defects were the major contributors to the excess grade 3-5 cumulative burden among survivors. Higher cardiac radiation dose (≥35 Gy) was associated with an increased grade 3-5 cardiovascular burden.InterpretationThe true impact of cardiovascular morbidity among pediatric Hodgkin lymphoma survivors is reflected in the cumulative burden. 50-year-old Hodgkin survivors will experience over two times the number of chronic cardiovascular health conditions compared community-controls and, on average, have one severe/life-threatening/fatal cardiovascular condition. The cumulative burden metric provides a more comprehensive approach to evaluating overall morbidity and will assist clinical researchers when designing future trials and refining general practice screening guidelines.

A single-center randomized, controlled trial investigating the efficacy of a mHealth ECG technology intervention to improve the detection of atrial fibrillation: the iHEART study protocol.

BackgroundAtrial fibrillation is a major public health problem and is the most common cardiac arrhythmia, affecting an estimated 2.7 million Americans. The true prevalence of atrial fibrillation is likely underestimated because episodes are often sporadic; therefore, it is challenging to detect and record an occurrence in a “real world” setting. To date, mobile health tools that promote earlier detection and treatment of atrial fibrillation and improvement in self-management behaviors and knowledge have not been evaluated. This study will be the first to address the epidemic problem of atrial fibrillation with a novel approach utilizing advancements in mobile health electrocardiogram technology to empower patients to actively engage in their healthcare and to evaluate impact on quality of life and quality-adjusted life years. Furthermore, sending a daily electrocardiogram transmission, coupled with receiving educational and motivational text messages aimed at promoting self-management and a healthy lifestyle may improve the management of chronic cardiovascular conditions (e.g., hypertension, diabetes, heart failure, etc.). Therefore, we are currently conducting a randomized controlled trial to assess the efficacy of a mobile health intervention, iPhone® Helping Evaluate Atrial fibrillation Rhythm through Technology (iHEART) versus usual cardiac care.MethodsThe iHEART study is a single center, prospective, randomized controlled trial. A total of 300 participants with a recent history of atrial fibrillation will be enrolled. Participants will be randomized 1:1 to receive the iHEART intervention, receiving an iPhone® equipped with an AliveCor® Mobile ECG and accompanying Kardia application and behavioral altering motivational text messages or usual cardiac care for 6 months.DiscussionThis will be the first study to investigate the utility of a mobile health intervention in a “real world” setting. We will evaluate the ability of the iHEART intervention to improve the detection and treatment of recurrent atrial fibrillation and assess the intervention's impact on improving clinical outcomes, quality of life, quality-adjusted life-years and disease-specific knowledge.Trial registrationNCT02731326; Verified April 2016