Common Cardiovascular Conditions Research Articles

Abstract 20: Public Reporting of Mortality Rates for Cardiovascular Conditions Did Not Improve Patient Outcomes

Background: Public reporting may improve provider performance, although evidence for its impact has been mixed. In the U.S., public reporting of hospital performance became widespread in late 2004. Led by the Centers for Medicare and Medicaid Services (CMS), this program initially reported process-of-care metrics only, but in 2008 expanded to include public reporting of 30-day mortality rates. We set out to determine whether public reporting of mortality rates led to improvements in mortality rates for cardiovascular conditions. Methods: We used national Medicare data from 2005-2011 to compare trends in risk-adjusted 30-day mortality rates for acute myocardial infarction (AMI) and congestive heart failure (CHF), two publicly reported conditions, for hospitals participating in the Hospital Compare program throughout the study period. We considered 2005 through 2007 as the process reporting period (pre-mortality-reporting period), and 2008 through 2011 as the mortality reporting period. We performed linear regression analyses with hospital random effects to determine if trends in mortality changed after the implementation of public reporting of mortality rates. For comparison, we also selected two common non-reported cardiovascular conditions, atrial fibrillation and stroke, and examined trends in mortality rates over the same time period. Results: There were 3,617 hospitals in our sample. Mortality rates for AMI were improving at a rate of -0.09% per quarter during process reporting, but the improvement slowed to a rate of -0.05% per quarter during outcomes reporting (+0.04% per quarter, p=0.016). For CHF, mortality was improving at -0.03% per quarter during process reporting, but worsened at +0.06% per quarter during mortality reporting (change of +0.09% per quarter, p<0.001). Interestingly, improvements in mortality rates also slowed for the non-reported cardiovascular conditions over the study period (Table). Conclusions: We found that mortality rates for publicly reported conditions were improving slightly during the period when only processes of care were being reported, but that these improvements slowed or reversed once public reporting of mortality rates began. These findings suggest that public reporting may be necessary, but is clearly not sufficient, to improve patient outcomes.

Left Atrium: Still a Neglected Chamber?

It is widely recognized that an effective cardiovascular system is based upon both a good ventricular-vascular interplay and a good ventricular-atrial interaction in all the phases of cardiac cycle. Moreover, left atrial dysfunction has been identified to be contributory in several common cardiovascular conditions, such as heart failure, atrial fibrillation and valvular heart disease; for instance, a good anatomical and functional assessment of this cardiac chamber is mandatory. For this purpose a multimodality imaging approach – including two-dimensional and three-dimensional echocardiography, speckle tracking technique, cardiac computed tomography (CT) and cardiac magnetic resonance (CMR) – is the most suitable one to achieve the best functional and anatomical evaluation of this cardiac chamber.

ECI-2: Atrial Fibrillation and Outcomes in Heart Failure with Preserved Versus Reduced Left Ventricular Ejection Fraction

Background/AimsAtrial fibrillation (AF) and heart failure (HF) are two of the most common cardiovascular conditions nationally and AF frequently complicates HF. We examined how AF impacts adverse outcomes in HF with preserved left ventricular ejection fraction (HF-PEF) vs. reduced ejection fraction (HF-REF) within a large, contemporary cohort.MethodsWe identified all adults diagnosed with HF-PEF or HF-REF based on hospital discharge and ambulatory visit diagnoses and relevant imaging results between 2005–2008 from four health plans in the Cardiovascular Research Network. Data on demographic features, diagnoses, procedures, outpatient pharmacy use, and laboratory results were ascertained from health plan databases. Hospitalizations for HF, stroke, and any other reason were identified from hospital discharge and billing claims databases. Deaths were ascertained from health plan and state death files.ResultsAmong 23,644 patients with HF, 11,429 (48.3%) had documented AF (9,081 pre-existing, 2,348 incident). Compared with patients who did not have AF, patients with AF had higher adjusted rates of ischemic stroke (hazard ratio [HR] 2.47 for incident AF; HR 1.57 for pre-existing AF), hospitalization for HF (HR 2.00 for incident AF; HR 1.22 for pre-existing AF), all-cause hospitalization (HR 1.45 for incident AF; HR 1.15 for pre-existing AF), and death (incident AF HR 1.67; pre-existing AF HR 1.13). The associations of AF with these outcomes were similar for HF-PEF and HF-REF, with the exception of ischemic stroke.ConclusionsAF is a potent risk factor for adverse outcomes in patients with HF-PEF or HF-REF. Effective interventions are needed to improve the prognosis of these high-risk patients.

Cardiovascular Imaging of the Pregnant Patient

The purpose of this review is to describe the selection and methods of imaging of pregnant women with cardiovascular conditions. Common cardiovascular conditions may occur in 1% of all pregnant women. The selection and methods of imaging studies require thoughtful planning. Use of radiation, radiopharmaceuticals, and contrast agents should be minimized. Pulmonary and cardiac CT angiography deliver minimal fetal radiation, and ventilation-perfusion scintigraphy presents relatively low fetal irradiation. Cardiac catheterization, coronary angiography, and electrophysiologic procedures, including complex interventions, also cause relatively low fetal exposure. Even nuclear cardiology procedures are unlikely to exceed negligible-risk (50 mGy cutoff) fetal radiation doses.

Just 6 minutes to get to the heart of frailty: the walking test in geriatric cardiology

Frailty is a geriatric syndrome due to impaired physiological reserve and characterized by a reduced ability to cope with stressing situations. Frailty and cardiovascular diseases share a common biological pathway and cardiovascular conditions may facilitate the manifestation of clinical frailty. Frailty is identified in 25% to 50% of patients with cardiovascular diseases, with estimates varying depending on assessment methods and population under study. Frail patients with cardiovascular diseases, especially those undergoing invasive procedures, particularly because of coronary artery disease or heart failure, have a substantially higher likelihood of complications and adverse events when compared to robust patients. Gait speed is a simple and reliable measure for objectively identifying frailty in elderly patients with cardiovascular diseases. A performance marker like the 6-minute walking test should be considered for routine use as a prognostic indicator.

Atrial Fibrillation and Outcomes in Heart Failure With Preserved Versus Reduced Left Ventricular Ejection Fraction

BackgroundAtrial fibrillation (AF) and heart failure (HF) are 2 of the most common cardiovascular conditions nationally and AF frequently complicates HF. We examined how AF has impacts on adverse outcomes in HF‐PEF versus HF‐REF within a large, contemporary cohort.Methods and ResultsWe identified all adults diagnosed with HF‐PEF or HF‐REF based on hospital discharge and ambulatory visit diagnoses and relevant imaging results for 2005–2008 from 4 health plans in the Cardiovascular Research Network. Data on demographic features, diagnoses, procedures, outpatient pharmacy use, and laboratory results were ascertained from health plan databases. Hospitalizations for HF, stroke, and any reason were identified from hospital discharge and billing claims databases. Deaths were ascertained from health plan and state death files. Among 23 644 patients with HF, 11 429 (48.3%) had documented AF (9081 preexisting, 2348 incident). Compared with patients who did not have AF, patients with AF had higher adjusted rates of ischemic stroke (hazard ratio [HR] 2.47 for incident AF; HR 1.57 for preexisting AF), hospitalization for HF (HR 2.00 for incident AF; HR 1.22 for preexisting AF), all‐cause hospitalization (HR 1.45 for incident AF; HR 1.15 for preexisting AF), and death (incident AF HR 1.67; preexisting AF HR 1.13). The associations of AF with these outcomes were similar for HF‐PEF and HF‐REF, with the exception of ischemic stroke.ConclusionsAF is a potent risk factor for adverse outcomes in patients with HF‐PEF or HF‐REF. Effective interventions are needed to improve the prognosis of these high‐risk patients.

Abstract 57: Reduction Of Cardiovascular Admissions From The Emergency Department: A Coordination Of Care Model Using Early Access To Specialists After Normal Working Hours

BACKGROUND: Despite the implementation of diagnostic and treatment algorithms for many common cardiovascular (CV) complaints, identifying low- and intermediate-risk patients presenting to the emergency department (ED) who could be managed without hospital admission remains difficult. We hypothesized that the presence of an attending cardiologist in the ED after normal working hours can help reduce the number of avoidable CV admissions by providing ED physicians with the support needed to identify, manage, and safely transition patients to the outpatient setting. METHODS: Beginning 08/22/2011, an attending cardiologist was available to consult on ED patients on weekdays between 6PM and midnight. The study population included all patients seen in the ED of an academic medical center on weekdays from 08/22/2011 to 11/30/2011 presenting in the afternoon/evening with a primary diagnosis of chest pain, atrial fibrillation (Afib), congestive heart failure (CHF), and syncope (based on ICD-9 diagnostic coding). Consultations were requested by the ED attending for patients where the intention was for inpatient admission, or where the disposition decision was complex. Rates of inpatient admission and 30-day return visit to the ED were compared to the same time period in the previous year using the Fisher’s exact test. RESULTS: Among patients presenting to the ED with one of the diagnoses of interest during the study period, there was a significant decrease in the inpatient admission rate compared to the same period in 2010 (52.0% vs. 38.6%; p<0.001, see Figure). Baseline clinical characteristics of the 2 cohorts were similar. During the study period, 174 consults were performed by the evening attending cardiologist with the diagnoses of interest accounting for 53% (n=93) of these. The decrease in admission rate was largely driven by an increase in the proportion of patients with chest pain being managed with observation in the ED (36.9% vs. 51.1%; p<0.001), and a decrease in the percentage of patients with Afib being admitted (61.1% vs. 45.0%; p=0.02). The incidence of return visits to the ED within 30-days following discharge did not increase (13.0%, 46/353 vs. 8.8%, 35/399; p=0.08). CONCLUSION: A program involving cardiology staff in the coordination of disposition decisions in the ED after normal working hours resulted in a reduction in the number of inpatient admissions for common CV conditions without increasing the incidence of return visits to the ED within 30 days.

Reflections of Robert D. Conn, MD on 50 Years as a Cardiologist

James H. O'Keefe, MD, interviews Robert D. Conn, MD, who has recently retired after 50 years in cardiology as an academician and practitioner. The diagnosis and treatment of common cardiovascular conditions are compared and contrasted between 1960 and 2010, and “game changers” are discussed and placed in context with current and future practices, taking into account the impact of economic and sociological changes.

Quantification of myocardial oxygen consumption with 17O-CMR: initial study

Background Impaired myocardial oxygenation leading to ischemia is central to the pathophysiology of coronary artery disease and an important contributor to other common cardiovascular disease conditions such as left ventricular hypertrophy, dilated cardiomyopathy, renal heart disease and valvular heart disease. Positron Emission Tomography (PET) can quantify myocardial oxygen consumption (MVO2), but has limited applications due to its relatively low spatial resolution, high cost, and ionizing radiation. Purpose

Valvular Heart Disease: Diagnosis and Management

Valvular heart disease (VHD) encompasses a number of common cardiovascular conditions that account for 10% to 20% of all cardiac surgical procedures in the United States. A better understanding of the natural history coupled with the major advances in diagnostic imaging, interventional cardiology, and surgical approaches have resulted in accurate diagnosis and appropriate selection of patients for therapeutic interventions. A thorough understanding of the various valvular disorders is important to aid in the management of patients with VHD. Appropriate work-up for patients with VHD includes a thorough history for evaluation of causes and symptoms, accurate assessment of the severity of the valvular abnormality by examination, appropriate diagnostic testing, and accurate quantification of the severity of valve dysfunction and therapeutic interventions, if necessary. It is also important to understand the role of the therapeutic interventions vs the natural history of the disease in the assessment of outcomes. Prophylaxis for infective endocarditis is no longer recommended unless the patient has a history of endocarditis or a prosthetic valve.

High Prevalence of Abnormal Nocturnal Oximetry in Patients With Hypertrophic Cardiomyopathy

We sought to determine the prevalence of nocturnal oxygen desaturation and obstructive sleep apnea (OSA) in a population of patients with hypertrophic cardiomyopathy (HCM). The coexistence of sleep apnea and HCM, 2 common cardiovascular conditions, has been largely unrecognized in the treatment of patients with HCM. The nocturnal hypoxia-induced hyperadrenergic state in OSA is expected to worsen hemodynamics and outcomes in HCM. One hundred subjects with HCM between June 1, 2006, and July 14, 2008, were screened with nocturnal oximetry. Clinical variables were collected for statistical analysis. Oximetry was classified abnormal (suspicion of sleep-disordered breathing) in the presence of repetitive desaturation (> or =5 events/h) followed by a rapid return to baseline oxygen saturation (SaO(2)) level with a decrease of > or =4% and threshold of 90%. Seventy-one (71%) patients with HCM had abnormal nocturnal oximetry (71 +/- 9%, 95% confidence interval: 62% to 80%). Subjects with abnormal oximetry were older (age 59.5 +/- 15.3 years) and more were hypertensive (n = 39 [55%]) than those with normal oximetry (age 45.8 +/- 18.5 years, n = 9 [31%], p < 0.001, p = 0.03). Patients with HCM were more symptomatic in the presence of abnormal oximetry (New York Heart Association functional class II to III) (62% vs. 83%, p = 0.023). HCM patients had a higher prevalence of abnormal nocturnal oximetry (n = 71, 71%) compared with a control group of similar age and sex distribution (n = 49, 49%) (p = 0.001). Abnormal nocturnal oximetry is common in patients with HCM, suggesting that OSA is prevalent. OSA may impact hemodynamics and symptoms in HCM. Further studies are needed to determine the long-term benefit of OSA treatment on hemodynamics and disease progression in HCM.

Atrial Fibrillation in Heart Failure Patients

There is a sinister synergism between atrial fibrillation (AF) and heart failure (HF). These common cardiovascular conditions often co-exist and result in significant morbidity and mortality. Despite the extensive amount of research and literature about each of these disorders separately, randomised controlled clinical trial data concerning the management of AF in patients with HF are lacking. The recently published Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial elucidated the matter of rhythm versus rate control. In addition, non-pharmacological treatment approaches such as catheter ablation of AF and cardiac resynchronisation therapy are rapidly growing and are likely to alter AF management in HF patients in the near future.

Physical activity and health: Metabolic and cardiovascular issues

Currently, chronic non-communicable diseases, notably metabolic and cardiovascular diseases, are a major health-related burden of the populations of the industrialized and increasingly so also of the non-industrialized countries. Physical inactivity is one of the living habits that have been shown to be causally related to the most common metabolic and cardiovascular conditions, namely obesity, type 2 diabetes, metabolic syndrome, hypertension, coronary heart disease, stroke and peripheral arterial disease. The World Health Report 2002 estimates that globally the prevalence of physical inactivity among adults is at least 17%, and that of insufficient activity 41%, and that physical inactivity causes 1.9 million deaths and loss of 19 million disability-adjusted life-years (DALYs) annually, related to the health losses caused by coronary heart disease, stroke, breast cancer, colon cancer and type 2 diabetes. In Australia, DALY losses due to physical inactivity rank second (tobacco being first) among males and first among females. In Canada, physical inactivity is estimated to be attributable to 35.8% of coronary heart disease, 19.9% of stroke, 19.9% of hypertension, 19.9% of colon cancer, 11.0% of breast cancer and 19.9% of type 2 diabetes. The direct and indirect economic costs of physical inactivity in Canada are estimated to be 2.6% and those of obesity 2.2% of the total healthcare costs. These figures suggest that reaching sufficient levels of physical activity would decrease substantially the disease burden caused by metabolic and cardiovascular diseases. Evidence from a large number of observational studies and also from controlled trials indicates that the amount, strenuousness and type of physical activity needed to gain a substantial part of the potential health benefits is in principle feasible and safe for the majority of the people in industrial societies. However, changing physical activity habits at individual and especially at the population level have proved to be difficult. Therefore, effective measures are needed to increase people's opportunities and motivation to incorporate more physical activity into their daily lives. Healthcare personnel, particularly physiotherapists, have good opportunities to contribute to this important work.

Advances In The Prevention And Treatment Of Cardiovascular Disease

Over the past thirty-five years, U.S. age-adjusted mortality from cardiovascular disease declined 50 percent. This marked reduction reflects advances in the prevention, diagnosis, and treatment of common cardiovascular conditions. Pharmaceutical agents play a major role in prevention of atherosclerosis and its consequences: heart attack, stroke, and heart failure. Additionally, novel device-based therapies contribute to the decline in cardiac morbidity and mortality. Whereas innovative strategies based on accurate imaging of the heart and blood vessels are implemented widely now, hope exists that lifestyle changes, early risk-factor screening, and more efficacious drugs will strikingly reduce cardiovascular disease in the future.

Endothelial function and its assessment

Endothelial dysfunction is a characteristic aspect of most of the conditions associated with atherosclerosis and is commonly found as an early feature in atherothrombotic vascular disease. An appreciation of the underlying mechanisms of endothelial function, as well as dysfunction, is essential as this has critical influence on the different methods in the assessment of endothelial function and effects of various treatments on its quantification. Furthermore, endothelial dysfunction is recognised as a type of ‘target organ damage’ in common cardiovascular conditions (e.g., hypertension) and the area is of increasing interest for new drug development, as therapies that modulate the endothelium will have added advantages; thus, for the development of new/experimental drugs, an awareness of ways to assess the endothelium is necessary. In this review, an overview of different methods including biochemical markers, and invasive and non-invasive tools, to determine endothelial function is presented as well as their clinical relevance. Furthermore, the effects of various treatments on endothelial dysfunction and their underlying mechanisms are elucidated.

High incidence of elevated B-type natriuretic peptide levels and risk factors for heart failure in an unselected at-risk population (stage A): implications for heart failure screening programs.

Only early detection and treatment is likely to stem the current epidemic of heart failure (HF). Several common cardiovascular and metabolic conditions increase the risk of developing symptomatic HF, but its detection by a simple and reliable screening method has proved elusive. HF screening sessions were conducted in September and November 2001. Members of the community with HF risk factors (e.g., hypertension, coronary artery disease, diabetes mellitus, hyperlipidemia) were invited--all specifically without a history of HF. The screening included a history review, health history questionnaire, measurement of blood pressure and pulse, as well as a measurement of B-type natriuretic peptide (BNP) level. A total of 233 individuals attended these two sessions: 108 men and 125 women (mean age, 63 years). Of the 233 subjects screened, the majority (92%) had >or=1 risk factor with an average of 2.8 risk factors for HF. The most common risks included hyperlipidemia (112), hypertension (112), age >65 years (105), cigarette smoking (105), coronary artery disease (60), and diabetes mellitus (54). Many subjects also had symptoms consistent with HF, with most (182, 82%) recording >or=1 symptom. Blood pressure measurements revealed a mean systolic of 139 mm Hg and mean diastolic of 79 mm Hg; on the screening days, 48% and 59% of subjects demonstrated either systolic or diastolic blood pressures above normal, respectively. BNP levels ranged from 0-479 pg/mL with an average of 40 pg/mL. A total of 24 subjects (10.3%) had a BNP level >100 pg/mL, and a total of 32 subjects (13.7%) had a level >80 pg/mL. The follow-up data showed that all 24 subjects saw their physician within 6 months after the screening. By 12 months following the initial screening program, 21 of the 24 subjects with elevated BNP levels (88%) underwent further testing and 18 of the 24 (67%) had changes in their medications. BNP screening identifies subjects at high risk for developing HF. Most subjects at risk have multiple risk factors and abnormal blood pressure. Approximately 10% of this population tested with an abnormal level of BNP, higher than the Food and Drug Administration-assigned cut-point diagnostic for HF. Increased public and physician awareness and information are needed to transform screening opportunities into a strategic approach to improve health care and HF prevention.

Homocysteine as a risk factor in cardiovascular disease.

Homocysteine is a naturally occurring, sulphur amino acid of established clinical relevance. Excess homocysteine excretion is characteristic of patients with the rare inborn error of metabolism -- homocystinuria -- a connective tissue disorder with spontaneous, early dislocation of the ocular lens, marfanoid habitus, and mental retardation.[13] Homocystinuria is also characterized by early death due to vaso-occlusive disease, and is accompanied by hemostatic changes consistent with a thrombophilic state. Increased plasma homocysteine is associated with histopathologic evidence of vascular endothelial injury, vascular smooth muscle proliferation, and progressive arterial stenosis. After its identification, homocystinuria was studied by investigators hypothesizing that a milder disturbance of homocysteine metabolism might be a significant factor in common cardiovascular conditions and coagulopathies. It is only recently that strong evidence for this hypothesis has emerged. [8;11]

Transgenic animal models: new avenues in cardiovascular physiology.

Application of molecular genetic tools to inherited cardiovascular disorders has provided important insights into the molecular mechanisms underlying cardiomyopathies, arrhythmias, blood pressure regulation, and atherosclerosis. In addition, alteration of gene expression has been observed under common cardiovascular conditions such as cardiac hypertrophy and heart failure. Recent advances in transgenic and gene-targeting approaches allow a sophisticated manipulation of the mouse genome by gene addition, gene deletion, or gene modifications. These transgenic models enable the dissection of in vivo pathways responsible for these complex disease phenotypes. This review describes tissue-specific promoters suitable for targeting candidate genes to the cardiovascular system as well as a number of valuable transgenic animal models of blood pressure regulation, atherogenesis, defects in the coagulation system, cardiac hypertrophy, myocarditis, cardiomyopathies, and heart failure. Limitations and difficulties associated with these transgenic approaches are discussed. Animal models which may provide a basis for future gene therapy of cardiovascular diseases are introduced. Finally, methods are described to regulate the spatial and temporal expression level of a transgene, to inactivate a target gene in a tissue-specific manner, and to introduce specific mutations into the genome. These recent advances in transgenic technology are expected to have a considerable impact on cardiovascular research in the near future.

A survey of views on hormone replacement therapy

To investigate the attitude of consultant gynaecologists and general practitioners to various aspects of hormone replacement therapy and to compare the findings in these two groups. Anonymous postal survey of 589 general practitioners and 998 consultant gynaecologists; 373 (63%) and 655 (66%) valid replies, respectively, were received. Views on universal treatment of eligible women, indications for hormone replacement therapy, prescribing practice, pretreatment investigation, monitoring, and contraindications to treatment. More consultants (64%) than general practitioners (56%) thought hormone replacement therapy should be offered to all eligible women, with a significant trend against treatment amongst more senior consultants. Most practitioners were prepared to offer treatment before the cessation of menstruation, but only 27% of consultants and 11% of general practitioners recommended indefinite treatment. Most limited treatment to less than 10 years. Menopausal symptoms, premature natural and surgical menopause, and a family history of osteoporosis were regarded as indications for treatment, but less than half felt established osteoporosis an indication. Hormone replacement therapy was judged to reduce the risk of ischaemic heart disease and osteoporosis by both groups but there was less consensus on the prevention of cerebrovascular accident. In general, consultants had more faith in hormone replacement therapy as prophylaxis. One-quarter of consultants said that hormone replacement therapy should be initiated by consultants. Only 4% of general practitioners shared this view. About 30% of both groups required mammography, but less than 10% required sophisticated tests. A range of common cardiovascular conditions were regarded as contraindications, although general practitioners were more likely to regard thrombosis and cerebrovascular accident as contraindications. Breast cancer and a family history of breast cancer were regarded with suspicion by both groups. Practitioners were positively inclined to hormone replacement therapy, but many were unconvinced of its chronic use and use in those with cardiovascular conditions. There were differences in views as to who should initiate therapy.