Comorbidities Coronary Artery Disease Research Articles

The role of thyrostatic agents in the treatment of chronic heart failure patients with comorbid coronary artery disease and thyrotoxicosis

Background: Thyroid dysfunction exerts a pronounced effect on the cardiovascular system, and, if comorbid with an existing cardiovascular disorder, may lead to a significant deterioration in the outcome, thus obviating the need for timely diagnosis and therapy optimization.Aim: To evaluate the effect of combination therapy, including thyrostatics, on the clinical symptoms of chronic heart failure (CHF), heart rate variability, NT-proBNP concentration, and structural and functional parameters of the left heart in patients with comorbid coronary artery disease (CAD) and thyrotoxicosis.Materials and methods: This open-label comparative study included 77 patients aged 45–65 years. The study group consisted of 36 patients with thyrotoxicosis, CAD and CHF II–III functional class, whereas the comparison group consisted of 41 patients with thyrotoxicosis without cardiovascular diseases. The patients were assessed clinically at baseline and after 6 months of therapy with addition of a thyrostatic, with tolerance to physical activity, measurements of NT-proBNP levels, 24-hour Holter monitoring, and echocardiography.Results: At 6 months of the combination therapy including a thyrostatic, with stable drug-induced euthyroidism, the patients in the group 1 showed an increase in the distance of a 6-minute walking test (p<0.001) and a decrease in CHF clinical symptoms. The incidence of heart rhythm disorders decreased (supraventricular extra systoles from 31% to 16%, ventricular extra systoles from 21% to 4%, atrial fibrillation from 32% to 23%; p<0.05), with a positive trend for spectral and temporal parameters of heart rate variability. The NT-proBNP level in patients with CAD, CHF and thyrotoxicosis decreased by 42.9% (p=0.001). During euthyrosis, echocardiography in the patients with ischemic CHF and concomitant thyrotoxicosis showed a significant increase in stroke volume (p=0.03), stroke ejection index (p=0.04), left ventricular ejection fraction (p=0.01), a decrease in the value of myocardial stress (p=0.02), and transmitral blood flow parameters (E/A, p<0.05). This indicates an improvement in systolic and diastolic left ventricular function after normalization of thyroid function.Conclusion: The inclusion of thyreostatics to the combination therapy and the achievement of euthyrosis have contributed to increased tolerance to physical activity, reduction of sympathetic activity level of the autonomic nervous system and frequency of heart rhythm disorders, reduced the NT-proBNP levels, improved systolic and diastolic left ventricular function in patients with ischemic CHF and concomitant thyrotoxicosis.

Evalution of the effect of obesity-associated inflammation on the response to complex therapy in hypertensive elderly patients with coronary artery disease

Object: to identify factors that limit the effectiveness of pharmacotherapy of hypertension (HT) with comorbid coronary artery disease (CAD) in elderly obese patients by determining laboratory and spectroscopy features related to inflammation. Material and methods: 60 patients (68.2 ± 5.9 y.o.) were observed and treated in Internal Medicine Department of University Clinic of Odessa National Medical University. Patients were divided into 2 groups. The 1st group included patients (n = 30) with body mass index (BMI) ≤25 kg/m2, HT and co-morbid CAD; the 2nd group (n = 30) - patients with BMI≥30 kg/m2, HT and with co-morbid CAD. For each patient’s group antihypertensive combination of Lisinopril and Bisoprolol was prescribed. The Laser correlation spectroscopy (LCS) was a special method for investigation. Results: before pharmacotherapy (PT) in both groups according to LCS 11-150 nm particles are prevailing. But in obese patients 75th percentile of 31-70 nm particles exceeds that one in non-obese group (56.7% vs 30.5%). During PT systolic blood pressure (SBP) value normalized in the patients of 1st group (without obesity), while in the obese patients (2nd group) SBP remained above target level. Creatinine level increased in patients of 1st group (without obesity) by 16.5 μmol / L (p <0.05) with a decrease in GFR by 17.1 ml/min/1.73 m2 (P <0.05). LCS data during PT show increase of 11-30 nm and decrease of 75-150 nm particles in non-obese patients, while in obese patients 71-150 nm particles are prevailing and 150 nm particles have appeared (p<0.05). Conclusions: 1. In elderly hypertensive patients with concomitant CAD, obesity is a factor limiting the effectiveness of complex antihypertensive therapy. 2. An increase of proportion of allergic-directed and appearance of autoimmune-directed homeostatic shifts in serum according to LCS are associated with a decrease of antihypertensive therapy efficacy in elderly hypertensive patients with CAD and obesity. 3. In hypertensive non-obese patients with CAD under the influence of complex antihypertensive therapy deteriorating of renal function is observed while in obesity renal function is not changed. 4. Homeostatic changes revealed in the second group by LCS values probably reflect manifestation of low grade inflammatory process caused by excessive activity of adipose tissue.

Abstract P113: Underestimation Of Sudden Death Due To Restrictive Sudden Cardiac Death Criteria

Background: Efforts to prevent sudden death may be hampered by restrictive case definitions impairing accurate estimates of incidence and risk factors of sudden death. Sudden cardiac death (SCD) definitions include requirements for presence of comorbid coronary artery disease (CAD) and various time criteria since onset of symptoms or when victims were last seen well. We compared prevalence of three SCD definitions within a registry of all-cause natural, sudden deaths. Hypothesis: We assessed the hypothesis that the restrictive criteria of three SCD definitions underestimate sudden death and exclude populations with increased medical comorbidities. Methods: Using a registry of 399 adjudicated sudden death cases among adults aged 18-64 in Wake County, North Carolina in 2013-2015, we included 271 cases after excluding for missing values, chronic kidney disease, or heart failure. Time since last seen alive was classified as less than one hour or 24 hours from scene reports. Presence of CAD and co-morbidities were defined from clinical or autopsy records. Prevalence of SCD using criteria defined by Atherosclerosis Risk in Communities (ARIC), the World Health Organization (WHO), and the Oregon Sudden Unexpected Death (SUD) registry were calculated. Prevalence of SCD risk factors were calculated for the 3 SCD subgroups and compared to the original 271 victims using two-sample t-test and Fisher’s exact test for continuous and categorical variables. Results: Among the 271 cases, criteria were met for the three SCD definitions for n (%): ARIC 28 (10%), WHO 54 (20%), and SUD 90 (33%) (Table 1). ARIC and WHO-defined SCD cases were younger than the original 271 cases. There were no significant differences in sociodemographic and clinical factors by any SCD group compared to the original 271 cases. Conclusion: Restrictive SCD definitions that require the presence of CAD or a specific time frame of identification of death underestimate the incidence of sudden death and hinder effective prevention efforts for sudden death.

Guideline-directed medical therapies for comorbidities among patients with atrial fibrillation: results from GARFIELD-AF

Abstract Introduction The GARFIELD-AF registry is a prospective, multicentre, observational study of adults with recently diagnosed non-valvular atrial fibrillation (AF) and at least one risk factor for stroke. In GARFIELD-AF the absolute risk reduction of mortality associated with anticoagulation is far greater than the apparent absolute risk reduction in (ischemic) stroke. One potential explanation is improved treatment, with the use of comprehensive guideline-directed medical therapies (GDMT), in patients with AF receiving oral anticoagulant (OAC) therapy. The objectives were to identify the potential relationships between anticoagulation status, GDMT use and clinical outcomes. Methods Use of GDMT was determined on the basis of published European Society for Cardiology guidelines operative between 2010 and 2016. We explored the use of GDMT in patients enrolled in GARFIELD-AF (March 2010-Aug 2016) with CHA2DS2-VASc ≥2 and with one or more of five comorbidities–coronary artery disease, diabetes mellitus, heart failure, hypertension and peripheral vascular disease. Association between GDMT use and clinical outcomes events was evaluated with Cox-proportional hazards models. The models included stratification by all possible combinations of the five comorbidities used to define GDMT eligibility. Results The study population comprised of 39,946 patients who had one or more comorbidities (3238 [8.1%] received none of the GDMT, 17,398 [43.6%] received some, and 19,310 [48.3%] received all of the GDMT for which they were eligible). Patients on OAC tended to receive all the GDMTs more frequently compared to patients on no OAC (50.2% vs 44.8%, respectively). Comprehensive GDMT was associated with a lower risk of all-cause mortality (HR: 0.89 [0.80–0.99]) and non-cardiovascular mortality (0.80 [0.68–0.95]) compared to inadequate or no GDMT but was not associated with a lower risk of stroke (HR: 1.04 (0.88–1.24)] (Figure). The effect of OAC was beneficial for mortality and stroke risk whether receiving comprehensive GDMT or not. Conclusion OAC therapy is associated with a lower risk of all-cause mortality, non-cardiovascular mortality and stroke/SE in comparison with no OAC, irrespective of GDMT use in patients with CHA2DS2-VASc ≥2. Although the use of GDMT is associated with a significant reduction in mortality, there is little evidence that this explains the decrease in mortality with the use of OAC. GDMT use at two years of follow-up Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): The GARFIELD-AF registry is funded by an unrestricted research grant from Bayer AG.

Особливості клінічного перебігу артеріальної гіпертензії у військовослужбовців в різні періоди після участі в ліквідації наслідків Чорнобильської катастрофи

SummaryThe purpose of the study was to assess the peculiarities of the clinical course ofarterial hypertension (AH) in military personnel who participated in the liquidation ofthe consequences of the Chernobyl disaster (LCCD) in the medium and long term periodafter participating in the LCCD.Materials and methods. A retrospective examination of 59 servicemen with AHafter (15.9±0.5) years after LCCD and 337 servicemen with AH after (27.6±1.4) yearsfrom LCCD, who had received low doses of ionizing radiation, was made.Results and discussion. In the LCCD patients, the frequency of detection ofconcomitant coronary artery disease (CAD) is 32.2 and 82.8% respectively, dependingon the time after exposure, significantly exceeds the indicator in the population forpersons of the same age (27.3–26.6%) and in outpatients with AH (66%). Moreover, thefrequency of painful forms of CAD (stable exertional angina) increases from 8 to 46%depending on the observation period.The frequency of detecting heart failure (HF) among the examined LCCD patientsreached 32.2% already 15 years after irradiation, and with longer follow-up – 82.8%,significantly exceeded the frequency of detecting the syndrome in the population of thecorresponding age (up to 16%), as well as among persons with comorbidity (AH andCAD) at a significantly older age (29.6%).Conclusions. Small doses of ionizing radiation significantly affect the health ofpersons even after (15.9±0.5) and (27.6±1.4) years after exposure of a radiation. Thehigher prevalence of comorbid CAD and HF in LCCD patients with AH both in the midterm and in the separate follow-up period can be explained not only by an increase inthe duration of AH and the age of patients, but also by the influence of a compound offactors of the Chernobyl disaster that requires further study.

Sex Differences and Long-Term Outcome in Patients With Pacemakers.

Introduction: Evidence of sex-related differences in patients with pacemakers regarding comorbidities is insufficiently investigated. The aim of this study was to determine the relationship of cardiovascular comorbidities and sex category with properties of pacemaker implantation, pacemaker follow-up, and long-term survival.Methods: This retrospective, single-center cohort study consisted of 6,362 pacemaker-patients (39.7% female) enrolled between May 2000 and April 2015. Functional pacemaker parameters were registered at regular pacemaker controls. Survival status and cause of death were analyzed in relation to comorbidities, implanted pacing devices, and echocardiography. Survival analyses were plotted for a 10-year follow-up.Results: Patients with hypertension or hyperlipidemia had higher rates of implantations due to sick sinus syndrome (28.6 vs. 25.5% without hypertension, P < 0.001; 30.7 vs. 25.7% without hyperlipidemia, P < 0.001), while endocarditis was associated with higher rates of implantations due to AV block (46.7 vs. 33.4%, P < 0.001). Patients with valvular heart disease had higher rates of pacemaker implantation due to bradycardic atrial fibrillation (24.9 vs. 21.0% without valvular heart disease, P < 0.001). Ventricular pacing threshold increased in both sexes during the follow-up and was higher in women in the final follow-up (0.94 vs. 0.91 V in men, P = 0.002). During the 10-years follow-up, 6.1% of women and 8.6% of men underwent lead replacement (P = 0.054). Device and lead replacement rates were increased if the comorbidities coronary artery disease, heart failure, hypertension, hyperlipidemia, valvular heart disease, previous stroke/TIA, atrial arrhythmias, chronic kidney disease, or endocarditis were present. Diabetes and previous CABG increase the rates of device replacement, but not the rate of lead replacement. Severe tricuspid regurgitation after implantation of pacemaker was present in more men than women (14.4 vs. 6.1%, P < 0.001). In a multivariate COX regression, the following variables were associated with independent decrease of 10-year survival: hypertension (HR 1.34, 95% CI 1.09–1.64), chronic kidney disease (HR 1.83, 95% CI 1.53–2.19), tricuspid regurgitation after pacemaker implantation (HR 1.48, 95% CI 1.26–1.74). Survival was independently increased in female sex (HR 0.83, 95% CI 0.70–0.99) and hyperlipidemia (HR 0.81, 95% CI 0.67–0.97).Conclusions: Cardiovascular comorbidities influenced significantly pacemaker implantations and long-term outcome.Trial Registration: ClinicalTrials.gov Unique identifier: NCT03388281.

P4778Effectiveness and safety of rivaroxaban versus warfarin in nonvalvular atrial fibrillation patients with coronary or peripheral artery disease

Abstract Background The efficacy and safety of rivaroxaban use for the prevention of major thrombotic vascular events (MTVEs) has been demonstrated in randomized trials of nonvalvular atrial fibrillation (NVAF), coronary artery disease (CAD) and peripheral artery disease (PAD) patients. Purpose To assess the effectiveness and safety of rivaroxaban versus warfarin in preventing MTVEs in NVAF patients with concomitant CAD and/or PAD in routine practice. Methods Using MarketScan data from 1/2012–12/2017, we identified oral anticoagulant (OAC)-naïve NVAF patients with comorbid CAD and/or PAD and ≥12-months of insurance coverage before OAC initiation. Differences in baseline covariates between cohorts were adjusted using inverse probability-of-treatment weights based on propensity-scores (standardized differences &lt;0.1 achieved for all covariates after adjustment). The primary effectiveness endpoint was the composite of any MTVE including ischemic stroke, myocardial infarction or adverse limb event (revascularization or amputation). The primary safety endpoint was major bleeding defined using the Cunningham algorithm. Patients were followed until a MTVE, discontinuation or switch of index OAC, insurance disenrollment or end-of-data availability. Hazard ratios (HRs) and 95% confidence intervals (CIs) comparing the cohorts were calculated using Cox regression. Results We identified 3,257 rivaroxaban (30.4% received a reduced dose) and 5,046 warfarin users with NVAF and comorbid CAD and/or PAD. Median (25%-75% range) age was 74 (65–81) years, CHA2DS2-VASc score was 3 (2–4). Rivaroxaban was associated with a 32% (95% CI=8–50%) reduction in the composite of any MTVE (Figure). No significant difference in major bleeding was observed (HR=1.13, 95% CI=0.84–1.52). Figure 1. Event Rates and Hazard Ratios Conclusions In patients with NVAF and comorbid CAD and/or PAD treated in routine practice, rivaroxaban use appears to reduce patients' risk of MTVEs compared to warfarin, without increasing their risk of major bleeding. This study lends further support to RCT findings that suggest rivaroxaban is effective in preventing major events in multiple vascular beds. Acknowledgement/Funding Bayer AG, Berlin, Germany

Effects of a mental stress challenge on brain function in coronary artery disease patients with and without depression.

Coronary artery disease (CAD) patients with comorbid depression show an increase in mortality compared to cardiac patients without depression, but the mechanisms mediating this effect remain obscure. One possible explanation for this finding is that depressed patients with CAD exhibit an increased vulnerability to stress. The purpose of this study was to assess the effects of stress and depression on brain function and to explore its relationship with myocardial ischemia in CAD patients. Patients with CAD and depression (N = 13) and CAD without depression (N = 15) underwent imaging of the brain with positron emission tomography and [O-15] water and imaging of the heart with single photon emission computed tomography (SPECT) and [Tc-99m] sestamibi under mental stress task and control conditions. CAD patients with depression compared to nondepressed showed decreased function with mental stress in the rostral anterior cingulate, the hippocampus, parts of the dorsolateral temporal and parietal cortex, the cerebellum, and the uncus, with increased blood flow in the parahippocampus, visual association cortex, and posterior cingulate. Depressed CAD patients who became ischemic during a mental stress task had relative decreases in the caudal and posterior cingulate, orbitofrontal cortex, and cerebellum, and increased activation in the parietal cortex and precuneus/visual association cortex compared to nonischemic depressed CAD patients. These findings are consistent with dysfunction in a network of brain regions involved in the stress response in patients with comorbid CAD and depression that has direct and indirect links to the heart, suggesting a pathway by which stress and depression could lead to increased risk of heart disease related morbidity and mortality. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Hybrid, Transcatheter Aortic Valve Implantation (TAVI) and Total Arterial Off-Pump Coronary Artery Bypass (OPCAB) in a Patient with Severe Aortic Valve Regurgitation – A Case Report

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been shown to be an effective growing strategy for severe, symptomatic aortic valve stenosis (AS) in patients who are either not ideal candidates or who are at intermediate or high surgical risk for surgical aortic valve replacement. Hybrid TAVI and off-pump coronary artery bypass graft (OPCAB) have been previously reported in high-risk patients with severe AS and coronary artery disease (CAD). TAVI data for severe aortic valve regurgitation (AR) is limited and currently considered an off-label application. Reports on hybrid TAVI for severe AR and OPCAB in patients with severe co-morbid CAD are limited. We report a hybrid TAVI and OPCAB in a 64-year-old female, with severe AR, severe left ventricular systolic dysfunction and CAD with a low take-off of the left main (LM) and porcelain aorta. CASE REPORT: The patient is a 64-year-old morbidly obese Filipino female with porcelain aorta and post-percutaneous coronary intervention with drug-eluting stent implantation for multivessel CAD with LM involvement and was admitted for refractory heart failure. Her 2D echocardiography demonstrated a dilated left ventricle with 19% left ventricular ejection fraction (LVEF) and severe AR. Computed tomography angiography demonstrated porcelain aorta, a low take-off of the left main with good femoral access. Hybrid TAVI with 26 mm Corevalve was done via the transfemoral approach after OPCAB of the left internal mammary artery to left anterior descending artery. Valve-in-valve transcatheter aortic valve replacement was required due to low valve implantation and severe paravalvular leak (PVL). Follow-up echo at 22 months demonstrated no PVL, 1.6 cm2 effective orifice aortic valve area, 12.4 mmHg mean gradient and 50% LVEF. She remains asymptomatic and in functional class I. CONCLUSION: Hybrid TAVI and OPCAB in patients with severe valvar AR, porcelain aorta and CAD represents a feasible and effective option of care. There are few reports in the literature documenting the effectiveness or feasibility of this approach for such patients.

Underuse of Prevention and Lifestyle Counseling in Patients With Peripheral Artery Disease

BackgroundLittle is known about patterns of medication use and lifestyle counseling in patients with peripheral artery disease (PAD) in the United States. ObjectivesThe authors sought to evaluate trends in both medical therapy and lifestyle counseling for PAD patients in the United States from 2005 through 2012. MethodsData from 1,982 outpatient visits among patients with PAD were obtained from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, a nationally representative assessment of office-based and hospital outpatient department practice. Trends in the proportion of visits with medication use (antiplatelet therapy, statins, angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers [ARBs], and cilostazol) and lifestyle counseling (exercise or diet counseling and smoking cessation) were evaluated. ResultsOver the 8-year period, the average annual number of ambulatory visits in the United States for PAD was 3,883,665. Across all visits, mean age was 69.2 years, 51.8% were female, and 56.6% were non-Hispanic white. Comorbid coronary artery disease (CAD) was present in 24.3% of visits. Medication use for cardiovascular prevention and symptoms of claudication was low: any antiplatelet therapy in 35.7% (standard error [SE]: 2.7%), statin in 33.1% (SE: 2.4%), ACEI/ARB in 28.4% (SE: 2.0%), and cilostazol in 4.7% (SE: 1.0%) of visits. Exercise or diet counseling was used in 22% (SE: 2.3%) of visits. Among current smokers with PAD, smoking cessation counseling or medication was used in 35.8% (SE: 4.6%) of visits. There was no significant change in medication use or lifestyle counseling over time. Compared with visits for patients with PAD alone, comorbid PAD and CAD were more likely to be prescribed antiplatelet therapy (odds ratio [OR]: 2.6; 95% confidence interval [CI]: 1.8 to 3.9), statins (OR: 2.6; 95% CI: 1.8 to 3.9), ACEI/ARB (OR: 2.6; 95% CI: 1.8 to 3.9), and smoking cessation counseling (OR: 4.4; 95% CI: 2.0 to 9.6). ConclusionsThe use of guideline-recommended therapies in patients with PAD was much lower than expected, which highlights an opportunity to improve the quality of care in these high-risk patients.

A Study on The Prevalence And Risk Factors Associated with Peripheral Vascular Disease In Type2 Diabetes Mellitus

A Study on The Prevalence And Risk Factors Associated with Peripheral Vascular Disease In Type2 Diabetes Mellitus

Management of concomitant coronary artery disease in patients undergoing transcatheter aortic valve implantation: The United Kingdom TAVI Registry

BackgroundThe management and impact of concomitant coronary artery disease in patients referred for TAVI remains contentious. We describe the prevalence, clinical impact and management of coronary artery disease (CAD) in patients in the United Kingdom TAVI Registry. MethodsAll-inclusive study of patients undergoing TAVI in the United Kingdom (excluding Northern Ireland) from January 2007 to December 2011. Coronary artery disease at the time of TAVI was demonstrated on invasive angiography. Results2588 consecutive patients were entered in the U.K. TAVI Registry. CAD was reported in 1171 pts with left main stem involvement in 12.4% of this cohort (n=145). Most patients were free of chest pain, but limited by dyspnoea (NYHA Class III & IV 81.9%). Angina was however more prevalent in those patients with CAD (p<0.0001). Hybrid PCI was uncommon, performed in only 14.7% of the CAD cohort (n=172).Survival at 30days, 1year, and 4years was 93.7%, 81.4% and 72.0% respectively. Adjusting for confounders in a multivariate model the presence and extent of CAD was not associated with early (30-days, p=0.36) or late (4years, p=0.10) survival. ConclusionsThis contemporary study of coronary artery disease management in an “all-comers” patient population undergoing TAVI demonstrates that whilst often an indicator of significant underlying comorbidity coronary artery disease is not associated with decreased short or long-term survival.The majority of patients with aortic stenosis and concomitant CAD can be managed effectively by TAVI alone. However, the importance of the Heart Team in making decisions on individual patients must not be underestimated.

Neuro-humoral control during orthostasis in health and disease.

Different from many other species, human beings spend nearly two-thirds of the day in an upright posture. Due to gravity, about 700 to 900 ml of blood shift into the lower body during quiet standing. As a result, central blood volume decreases and this leads to a series of neural-humoral adjustments that aim to maintain the mean arterial pressure during orthostasis. Both the sympathetic nervous system and the renin-angiotensin-aldosterone system contribute importantly to the arterial pressure maintenance in upright humans. There is a growing interest in the blood pressure regulation during orthostasis in healthy individuals and patient populations. This e-book provides some updates on sympathetic neural control and renal-adrenal function in health and disease. Sympathetic neural activity regulates blood pressure mainly through the baroreflex-mediated vasoconstriction during orthostasis. The baroreflex is a closed-loop feedback system, but requires open-loop experiments to identify its characteristics, which is impossible in human research. Kamiya et al. demonstrated that system identification based analysis and numerical simulation using baroreflex subsystem characteristics identified in animal models may contribute to our understanding of human sympathetic physiology under orthostasis (Kamiya et al., 2014). Neural and renal-adrenal control of blood pressure can be affected by not only age but also race and physical fitness. For example, it was found that young normotensive Caucasian women may rely on sympathetic neural activity more so than African-American women who had a tendency to rely on the renal-adrenal system to regulate blood pressure during orthostatic challenges (Jarvis et al., 2014). Conversely, Sugawara et al. reported that endurance-trained men had increased orthostatic tachycardia and enhanced cardiovagal baroreflex sensitivity, which may favorably mitigate accumulated risks for post-exercise orthostatic intolerance (Sugawara et al., 2014). Failure of the sympathetic nervous system during orthostasis may result in syncope (Iwase et al., 2014). However, orthostatic tolerance does not seem to be related to resting sympathetic neural activity or sympathetic baroreflex sensitivity (Hinojosa-Laborde et al., 2014). Studies in healthy young individuals indicate that in addition to sympathetic vasoconstriction, the heart rate response may also contribute importantly to orthostatic tolerance (Convertino, 2014). On the other hand, it is argued that cardiac effector mechanisms appear not to be important for the adjustment of arterial pressure to the upright posture in humans (Wieling et al., 2014). Indeed, investigations into the role of the sympathetic nervous system in orthostatic intolerance have yielded mixed results. The review article by Lambert and Lambert (2014) outlines the current knowledge of the function of the sympathetic nervous system in vasovagal syncope and the Postural Orthostatic Tachycardia Syndrome (POTS, also called Chronic Orthostatic Intolerance). There are multiple pathophysiological mechanisms that underlie POTS; some POTS patients have evidence of elevated sympathoneural tone, others have a hypovolemic state, and many patients have a perturbed renin-angiotensin-aldosterone system profile (Mar and Raj, 2014). Patients with POTS have acute changes in cognitive performance in response to orthostatic challenges, and these patients also have an increased prevalence of depression and higher levels of anxiety (Anderson et al., 2014). Impaired cerebral autoregulation may underlie upright cognitive dysfunction in POTS (Medow et al., 2014). Finally, patients with autonomic failure often have orthostatic hypotension and (pre)syncopal symptoms. Arnold et al. showed that ergotamine combined with caffeine could be used as an alternate treatment in carefully selected patients without comorbid coronary artery disease (Arnold et al., 2014). Taken together, this e-book highlights only a small portion of the recent advances in neural-humoral control during orthostasis in humans. More research is needed to better understand the role of the sympathetic nervous system and the renin-angiotensin-aldosterone system in the regulation of blood pressure in health and disease.

Combination ergotamine and caffeine improves seated blood pressure and presyncopal symptoms in autonomic failure.

Severely affected patients with autonomic failure require pressor agents to counteract the blood pressure fall and improve presyncopal symptoms upon standing. Previous studies suggest that combination ergotamine and caffeine may be effective in the treatment of autonomic failure, but the efficacy of this drug has not been evaluated in controlled trials. Therefore, we compared the effects of ergotamine/caffeine on seated blood pressure and orthostatic tolerance and symptoms in 12 primary autonomic failure patients without history of coronary artery disease. Patients were randomized to receive a single oral dose of placebo, midodrine (5–10 mg), or ergotamine and caffeine (1 and 100 mg, respectively) in a single-blind, crossover study. Blood pressure was measured while patients were seated and after standing for up to 10 min, at baseline and at 1 h post-drug. Ergotamine/caffeine increased seated systolic blood pressure (SBP), the primary outcome, compared with placebo (131 ± 19 and 95 ± 12 mmHg, respectively, at 1 h post-drug; p = 0.003 for time effect). Midodrine also significantly increased seated SBP (121 ± 19 mmHg at 1 h post-drug; p = 0.015 for time effect vs. placebo), but this effect was not different from ergotamine/caffeine (p = 0.621). There was no significant effect of either medication on orthostatic tolerance; however, ergotamine/caffeine improved presyncopal symptoms (p = 0.034). These findings suggest that combination ergotamine and caffeine elicits a seated pressor response that is similar in magnitude to midodrine, and improves symptoms in autonomic failure. Thus, ergotamine/caffeine could be used as an alternate treatment for autonomic failure, in carefully selected patients without comorbid coronary artery disease.

MP76-09 FACTORS ASSOCIATED WITH POOR RETURN OF URINARY FUNCTION AFTER ROBOTIC ASSISTED RADICAL PROSTATECTOMY: EVALUATION OF EXPANDED PROSTATE CANCER INDEX COMPOSITE (EPIC) SCORES

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Non-neurogenic Voiding Dysfunction1 Apr 2014MP76-09 FACTORS ASSOCIATED WITH POOR RETURN OF URINARY FUNCTION AFTER ROBOTIC ASSISTED RADICAL PROSTATECTOMY: EVALUATION OF EXPANDED PROSTATE CANCER INDEX COMPOSITE (EPIC) SCORES David Pridmore, Charity Chen, Kim Killinger, Kenneth Peters, Jay Hollander, and Jason Hafron David PridmoreDavid Pridmore More articles by this author , Charity ChenCharity Chen More articles by this author , Kim KillingerKim Killinger More articles by this author , Kenneth PetersKenneth Peters More articles by this author , Jay HollanderJay Hollander More articles by this author , and Jason HafronJason Hafron More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2402AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Since the number of men surviving prostate cancer is rapidly growing, quality of life outcomes including specific health issues related to survivorship after radical prostatectomy are of increasing importance. We explored factors associated with return to baseline urinary function after robotic assisted radical prostatectomy (RARP). METHODS From October 2003 to June 2009 demographic and urinary function data were prospectively collected from 623 men that had RARP. Medical records were also reviewed. Men completed the Expanded Prostate Cancer Index Composite (EPIC) at baseline, and 6, 12, 18 and 24 months after RARP and the urinary function (EPIC-UF) subscale was evaluated. Return to baseline was defined as achieving an EPIC-UF score that was within 0.5 SD of baseline score at 2 years. Data were examined with t tests, Wilcoxon rank sum tests, and logistic regresssion. RESULTS Mean age was 60.02 ± 7.11 years. At baseline, a slight majority (382/622; 61.4%) had the maximum EPIC-UF score of 100; overall mean score was 93.97 ± 10.16. Of 521 men that had EPIC-UF data at both baseline and 24 months, 279/521 (53.6%) had returned to baseline function at 24 months. Univariate analyses found that when men that did/did not return to baseline function were compared, baseline EPIC-UF score of 100 vs.<100 (p=0.0159), body mass index (BMI) ≥ 30 (p=0.0091), history of smoking (p=0.0358), comorbid coronary artery disease (CAD) (p=0.0018), diabetes (p=0.0193), pathological stage T2 vs. T3 (p=0.0078), and ASA score (p=0.0153) were significantly different between groups. Age, race, education, employment, income, hypertension, nerve-sparing status, blood loss, and prostate weight did not differ significantly. Multivariable logistic regression analysis revealed that predictive factors associated with lack of return to baseline score included baseline EPIC-UF of 100 (p=0.0240), BMI ≥ 30 (p=0.0092), smoking (p=0.0358), comorbid CAD (p=0.0018), and stage T3 disease (p=0.0191). CONCLUSIONS Cancer survivorship issues after RARP may include ongoing urinary concerns. Surgeons need to understand the preoperative variables that may limit, or enhance, return to baseline urinary function in order to provide appropriate counseling to newly diagnosed men as well as continued treatment to survivors. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e885 Advertisement Copyright & Permissions© 2014MetricsAuthor Information David Pridmore More articles by this author Charity Chen More articles by this author Kim Killinger More articles by this author Kenneth Peters More articles by this author Jay Hollander More articles by this author Jason Hafron More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Clinical and pathogenic aspects of arterial stiffness and the left heart remodeling in patients with chronic obstructive pulmonary disease and coronary artery disease

Aim. The aim of this study was to evaluate a relationship between clinical and functional parameters, arterial stiffness and the left heart remodeling in patients with COPD and comorbid coronary artery disease (CAD). Methods . Fifty COPD patients with or without comorbid CAD were includ ed. This was a prospective observational 52week study. Lung function was testing, noninvasive arteriography, echocardiography were used. Oxygen saturation and cytokine (IL6, IL8, TNFα) were measured. Results . Severe and very severe COPD and CAD have common risk factors, such as smoking, hypoxemia, systemic inflammation, which can cause vascular wall remodeling. Increased arterial stiffness affects hemodynamics and impedes myocardial relaxation that in turn leads to diastolic dysfunction and reduced left heart contractility Direct relationships between systemic inflammation biomarkers, arterial stiffness, systolic and diastolic dysfunction were found in patients with severe and very severe COPD independ ently on comorbid CAD.

Saving a Life: Balancing Risks, Harms, and Benefits in Palliative Care

DOI: 10.1200/JCO.2013.53.9338 The letter from the hospital’s Office of Development was marked “Confidential.” No, we had not been offered the $10 million endowment I had been hoping for. But the letter, signed by the vice president of Development, was to inform me of a gift of $100 in my honor from a grateful patient. It read: “You are my special angel. Thank you for saving my life.” The donor was a woman in her sixties with metastatic breast cancer. She had been a patient of mine for only a few months. She was referred by her breast oncologist for assistance with pain management, and I had seen her in the clinic on only a handful of occasions. Hers was an unusual cancer story, at least in my experience. She had been diagnosed with triple-negative breast cancer six years ago, and it was metastatic to the bone at the time of diagnosis, but with only a solitary lesion in the sternum. This lesion had gotten progressively bigger over time, but her disease had never been found to have spread elsewhere. She had had multiple lines of chemotherapy, the prescription of which had been compromised by her comorbid coronary artery disease. Because her tumor was androgen receptor positive, she had been treated with hormonal therapies on two protocols, but these had had to be discontinued because of intolerable hot flashes. She was now on expectant observation. At the first consultation with me, the patient complained of long-standing pain in the sternum, which had increased in recent months and was excruciating, especially with movement, radiating to both breasts and into the right axilla and upper extremity at times. The latest positron emission tomography scan had again shown the large sternal lesion (5.2 4.6 5.2 cm), which had increased in size compared with the previous scans but with stable [F]fluorodeoxyglucose (FDG) avidity. A softtissue component extended both superficially and deep toward the sternum. There was associated increase in central FDG photopenia in the mass, representing central necrosis. There were no other FDG-avid foci of concern. Her oncologist had tried a fentanyl patch, but even at a dose of only 12 mcg per hour it caused bothersome adverse events (dizziness, dry mouth), so the treatment had been switched to oxycodone, which made her nauseous. Nonopioid analgesics were going to be challenging to use in her case, because of interactions with her cardiac medications and the antidepressants she was taking. Palliative radiation therapy to the sternum had already been given last year to the maximal dosage. Aside from pain and the adverse effects of the pain medicine, she was otherwise without complaint and had an excellent performance status. After a prolonged discussion about the pharmacologic options, she preferred to try fentanyl patches again rather than rotating to morphine or methadone. At the second clinic visit 3 weeks later, she continued to complain of sternal pain with associated numbness. She was tolerating the fentanyl better this time around but had no real improvement in the pain, despite titration of the dose to 37 g per hour. I informed her I would present her case at our monthly Combined Pain Services meeting to inquire about the possibility of intercostal nerve blocks, but I warned her they might not be feasible given that the lesion was so large and invasive. At the conference, my anesthesiology colleague opined that nerve blocks could be offered, but he also raised the option of palliative surgery. So I reached out to our cardiothoracic surgeon who reviewed the imaging and told me she would need a sternectomy, but the procedure could provide good palliation. When I communicated this to my patient, her initial reaction was unexpected. Rather than expressing anxiety, she expressed surprise and consternation, informing me that she had previously asked her oncologist about the possibility of surgery but that her request had been dismissed as an option. The patient called me back a few days later, asking for a referral to the cardiothoracic surgeon. When I informed her primary oncologist of my plan, he told me I was crazy because of her coronary artery disease and the fact that the tumor was abutting the pericardium. Nevertheless, the patient met with the surgeon and chose to have surgery. The procedure went smoothly, clear margins were obtained, and the reconstruction went well. The patient went home after 5 days and, over the next few JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 32 NUMBER 4 FEBRUARY 1 2014

SAT0262 Comorbidities Associated with Psoriatic Arthritis - A Longitudinal Observational Cohort Study.

BackgroundPsoriasis and Psoariatic arthritis (PsA) are chronic inflammatory diseases associated with other health concerns such as obesity, type II diabetes, dyslipidemia, hypertension and cardiovascular diseases. This association can be due...

What is the long-term prognosis for patients with coronary artery disease and von Willebrand's disease?

Evidence-Based Answer The long-term prognosis is unknown. No clinical studies have evaluated long-term outcomes in patients with von Willebrand's disease (vWD) and comorbid coronary artery disease (CAD). It is also unknown if there is an association between coronary heart disease (CHD) risk and decreased von Willebrand's factor (vWF) levels in the general population (no SOR, conflicting cohort studies and meta-analysis).

Risk of acute kidney injury after exposure to gadolinium-based contrast in patients with renal impairment

Background and Aims: Gadolinium-based contrast media (Gd-CM) are reported to induce acute kidney injury (AKI) in a high-risk population group at the usual dose for magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) examinations. We assessed gadolinium-induced nephropathy in patients with renal impairment who underwent MRI or MRA examinations, and evaluate the risk factors. Methods: In this retrospective study, 238 patients with baseline renal impairment, who received MRI or MRA examinations with Gd-CM, were recruited. Results: After all other AKI causes—liver decompensation, severe heart failure, all kinds of shock, and severe sepsis—and patients on dialysis were excluded, 158 patients were enrolled. AKI was defined as a decrease in GFR &gt; 10% of baseline data within 3 days after Gd-CM administration. Regression analysis was used to find independent risk factors for gadolinium-induced ARF (Gd-AKI) . Twenty-six of the 158 patients (16.5%) developed Gd-ARF. There were no significant differences in gender, age, or baseline eGFR between those who did and who did not develop AKI. Co-morbid coronary artery disease, liver cirrhosis, diabetic mellitus, and hypertension were not significantly associated with the development of Gd-ARF. However, sepsis was an independent risk factor for Gd-AKI after multivariate regression analysis (adjusted odds ratio: 4.417; 95% confidence interval: 1.671, 11.676, P =.03). Conclusions: Sepsis was an independent risk factor for Gd-CM nephropathy at the usual dose for MRI and MRA examinations. It is important to identify high-risk patients and closely monitor renal function after Gd-CM administration.