Poor Functional Capacity Research Articles

Pre-operative Cardiac Stress Testing in the So Cal VOICe

Peri-operative guidelines from the American College of Cardiology/American Heart Association recommend that for patients undergoing elective vascular surgery, pharmacologic stress testing be performed in patients with poor or unknown functional capacity in which further testing will impact decision making or perioperative care. The objective of this study is to examine the use of pre-operative cardiac stress testing (PCST) in the Southern California Vascular Outcomes Improvement Collaborative (So Cal VOICe).

Association of soluble ST2 with functional capacity in outpatients with heart failure

Biomarkers play an important role in the risk stratification of patients with heart failure (HF). Recent studies have shown that soluble suppression of tumorigenicity2 (sST2), a member of the interleukin1 receptor family, is associated with disease prognosis in acute and chronic HF. In this study we aimed to investigate the relation between sST2level and functional capacity in outpatients with systolic HF. This study included 120 HF patients with reduced ejection fraction (HFrEF; EF≤ 40%). The mean age of patients was 66± 11years. Advanced HF (New York Heart Association [NYHA] functional class III-IV) was observed in 35patients (29%). sST2levels were on average higher in patients with NYHA functional classes III and IV than in patients with NYHA functional classes I and II (51 [9-198] vs. 25 ng/ml [9-118], p< 0.001). In a multiple logistic regression model, sST2level (OR: 1.044, p= 0.004, 95% CI: 1.014-1.075), hemoglobin level (OR: 0.590, p= 0.001, 95% CI: 0.433-0.805), total cholesterol level (OR: 0.977, p= 0.004, 95% CI: 0.962-0.993), and age (OR: 1.066, p= 0.047, 95% CI: 1.001-1.136) were associated with poor functional capacity. In receiver operating characteristic (ROC) curve analysis, the optimal cut-off value of sST2 for predicting poor functional capacity was >42 ng/ml, with 63% sensitivity and 88% specificity (AUC: 0.810, 95% CI: 0.728- 0.875). Higher sST2levels were strongly associated with poor NYHA functional class, independent of cardiac risk factors, in outpatients with HFrEF.

Riociguat: a soluble guanylate cyclase stimulator for the treatment of pulmonary hypertension.

Despite advances in treatments and improved survival, patients with pulmonary hypertension still experience poor exercise and functional capacity, which has a significant detrimental impact on their quality of life. The nitric oxide (NO)–soluble guanylate cyclase (sGC)–cyclic guanosine 3′,5′-monophosphate (cGMP) pathway has been shown to play an important role in cardiovascular physiology, especially in vasodilation and pulmonary vascular tone. The oral sGC stimulator riociguat has a dual mode of action on the NO–sGC–cGMP pathway: direct stimulation of sGC independent of NO and indirect simulation via sensitization of sGC to endogenous NO. Riociguat is now licensed in >50 countries worldwide, including in Europe, the USA, Canada, and Japan. Approval for the treatment of pulmonary arterial hypertension (PAH) was based on Phase III data from the PATENT studies, in which riociguat significantly improved exercise capacity, pulmonary vascular resistance, a range of secondary end points, and hemodynamic parameters in patients with symptomatic PAH. In the Phase III CHEST studies, riociguat consistently improved exercise capacity in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) or persistent/recurrent CTEPH after pulmonary endarterectomy and is now the only drug to be approved for this indication. Riociguat was well tolerated in long-term studies of PAH and CTEPH. This review describes the role of the NO–sGC–cGMP pathway in the pathophysiology of pulmonary hypertension, and reviews the clinical efficacy and safety of riociguat in patients with PAH and inoperable or persistent/recurrent CTEPH. Based on its demonstrated efficacy and established safety profile, riociguat is a promising treatment option for patients with PAH and CTEPH.

Absolute iron deficiency without anaemia in patients with chronic systolic heart failure is associated with poorer functional capacity

Functional status is one of the main concerns in the management of heart failure (HF). Recently, the FAIR-HF and CONFIRM-HF trials showed that correcting anaemia using intravenous iron supplementation improved functional variables in patients with absolute or relative iron deficiency. Relative iron deficiency is supposed to be a marker of HF severity, as ferritin concentration increases with advanced stages of HF, but little is known about the impact of absolute iron deficiency (AID). To study the impact of AID on functional variables and survival in patients with chronic systolic HF. One hundred and thirty-eight non-anaemic patients with chronic systolic HF were included retrospectively. Patients were divided into two groups according to iron status: the AID group, defined by a ferritin concentration<100μg/L and the non-AID group, defined by a ferritin concentration≥100μg/L. Functional, morphological and biological variables were collected, and survival was assessed. Patients in the AID group had a poorer 6-minute walking test (342 vs. 387m; P=0.03) and poorer peak exercise oxygen consumption (13.8 vs. 16.0mL/min/kg; P=0.01). By multivariable analysis, ferritin<100μg/L was associated with impaired capacity of effort, assessed by peak exercise oxygen consumption. By multivariable analysis, there was no difference in total mortality between groups, with a mean follow-up of 5.1±1.1 years. The poorer functional evaluations in iron-deficient patients previously reported are not caused by the merging of two different populations (i.e. patients with absolute or relative iron deficiency). Our study has confirmed that non-anaemic HF patients with AID have poorer peak oxygen consumption. However, AID has no impact on the survival of these patients.

Somatic-Affective, But Not Cognitive-Depressive Symptoms are Associated With Reduced Health–Related Quality of Life in Patients With Congestive Heart Failure

Depression has been associated with poor health-related quality of life (HRQoL) in patients with congestive heart failure (CHF). However, to date, whether somatic-affective and cognitive-depressive symptoms differently contribute to poor HRQoL and behavioral functional capacity in patients with CHF has yet to be investigated. To examine the differential influence of somatic-affective vs cognitive-depressive symptoms on HRQoL and behavioral functional capacity in CHF patients. Overall, 55 patients with CHF completed a psychologic evaluation, including the Minnesota Living with Heart Failure Questionnaire, the Beck Depression Inventory-II, and the Beck Anxiety Inventory for HRQoL, depressive, and anxiety symptoms, respectively. The patients completed the Instrumental Activities of Daily Living Questionnaire and the 6-minute walk test for behavioral functional capacity. Hierarchical regression analyses were used to predict HRQoL and behavioral functional capacity from Beck Depression Inventory-II and Beck Anxiety Inventory scores. Somatic-affective depressive symptoms were associated with physical (β = 0.37, p = 0.005) and emotional (β = 0.39, p = 0.008) Minnesota Living with Heart Failure Questionnaire subscale scores. Likewise, somatic-affective depressive symptoms predicted Instrumental Activities of Daily Livings Scores (β = 0.43, p = 0.004) and distance ambulated during the 6-minute walk test (β = -0.36, p = 0.029). By contrast, cognitive-depressive symptoms and anxiety were unrelated to HRQoL and behavioral functional capacity (all p > 0.05). These findings showed that somatic-affective depressive symptoms, but not cognitive-depressive symptoms and anxiety, are associated with poor HRQoL and behavioral functional capacity independent of age, clinical functional status, and medical comorbidities. This study suggests that patients with CHF with somatic-affective rather than cognitive-depressive symptoms or anxiety may be at greater risk of poor HRQoL and behavioral functional capacity.

CHANGES IN FUNCTIONAL CAPACITY IN POSTMENOPAUSAL WOMEN ADHERING TO A MEDITERRANEAN DIET

Objectives: To evaluate whether Mediterranean style diet (MedSD) is associated with better physical performance. There is evidence from large epidemiological studies that MedSD associates with lower risk of chronic disease and mortality. Poor functional capacity, partially affected by poor physical performance, also predicts higher morbidity and mortality resulting in higher healthcare costs. Design: One group, longitudinal pilot clinical intervention trial of 24 weeks total; 12 weeks observation followed by 12 weeks intervention in 16 postmenopausal women (age&gt;65 y) evaluating effects on physical performance. Setting: Outpatient clinical research center. Participants: 16 postmenopausal women (age&gt;65 y) selected for typical American diet. Intervention: Women consumed their typical diet for 12 weeks followed by a 12-week MedSD intervention. A registered dietitian counseled the subjects to make 4 dietary changes: 1) incorporate 3 tablespoons Extra Virgin Olive Oil (EVOO) daily; 2) include 3-5 servings/week of high omega-3 fish (salmon or tuna); 3) incorporate 1.5 ounces of walnuts daily; 4) incorporate increased amounts of fruits, vegetables and whole grains. Measurement: Food frequency questionnaire scores, 3-day diet record, serum total fatty acids, anthropometry, physical activity, functional capacity (chair rise time, single leg time, hand grip strength were measured. Pre-post analysis compared the 2 weeks typical diet period with the 2 weeks MedSD intervention period. Correlations were used to relate dietary change to physical performance change. Results: Diet analysis revealed adherence to the MedSD (p = &lt; 0.001). No significant differences were observed in hand grip strength or the Short Physical Performance Battery. Significant correlations were found between change in chair rise time and changes in intake of carbohydrates (r= 0.587) and trans and saturated fat (r= 0.818). Inability to identify other significant correlations in primary outcomes was likely affected by small sample size and physically robust participant group. Conclusions: Alterations in consumption patterns to adhere to a MedSD, including reductions in saturated fat and carbohydrate consumption, correlate with improvement in chair rise time. This study design can be used for future studies with a larger group of frailer, older adults to assess the effect of MedSD on physical performance.

Hypertension and functional capacities in community-dwelling older women: a cross-sectional study

Purpose: The present study aimed to investigate the association between hypertension and physical/functional capacities in community-dwelling older females.Materials and methods: Older female volunteers were dichotomized in two groups: hypertensive (n = 134) and normotensive (n = 244). Volunteers had their medical records reviewed and underwent evaluations of anthropometric data (weight, height and body mass index) and of physical and functional capacities.Results: The results showed that hypertensive older females presented higher values for age, weight, body mass index, and resting diastolic blood pressure than normotensive older females. Normotensive older females showed a higher performance in the one-leg stand test and six-minute walk test compared with hypertensive older females. Age, body mass index, maximal walking speed, performance in the Time Up and Go and six-minute walk test, and diagnosis of diabetes mellitus type II were factors associated with hypertension using the chi-square test. However, the multivariate regression analysis indicated that performance in the six-minute walk test was the only factor associated with hypertension.Conclusions: The patients with higher scores in the six-minute walk test, which is associated with aerobic capacity, show less odds to have clinical diagnosis of hypertension. However, hypertension was not associated with poor physical and functional capacity.

Role of Left Atrial Reservoir Strain Rate in Left Atrial Remodeling in Severe Mitral Regurgitation

BackgroundImpaired left atrial (LA) reservoir deformation has been found to be associated with poor functional capacity and outcomes in severe chronic mitral regurgitation (MR). Among patients with primary MR (valve incompetence due to mitral valve pathology), we focus on Carpentier II classification (prolapse or flail mitral valve) and aim to investigate determinants for decreased LA reservoir deformation and its impact on LA remodeling in severe MR. MethodsAmong 159 consecutive patients with severe chronic Carpentier II MR (left ventricular ejection fraction≥60%), 55 underwent follow-up echocardiography, which was compared with their baseline study. We used the change of LA volume index as the rapidity of LA remodeling, LA eccentricity index as LA sphericity, and peak LA reservoir strain as well as reservoir strain rate (LASRR) derived from two-dimensional speckle-tracking echocardiography as LA reservoir function. ResultsOlder age, elongated left atrium, increased LA volume index, as well as reduced left ventricular global longitudinal strain and LA ejection fraction all linked to a poor baseline LASRR (all p<0.001). A second echocardiography during a mean follow-up of 15.3±8.3 months revealed an enlarged left atrium (increased interval change of LA volume index; p<0.001). In multivariate analysis, only the difference between the baseline and follow-up LASRR values (△LASRR; odds ratio (OR) 0.037, 95% confidence interval (CI) 0.003–0.496, p=0.013) predicted accelerated LA remodeling. A poor baseline LASRR was significantly associated with its profound deterioration during the follow-up period (β=−0.424, p=0.002). ConclusionIn severe chronic Carpentier II MR, a reduced follow-up LASRR predicted future accelerated LA remodeling. Patients with a poor baseline LASRR are at a higher risk of its deterioration.

The Incidence of Perioperative Adverse Events in the Very Elderly Undergoing Urogynecologic Surgery.

To determine the incidence of perioperative adverse events in very elderly women (age ≥ 80 years) undergoing urogynecologic procedures and to examine the effect of preoperative functional status/capacity on these outcomes. This is a retrospective analysis of all women aged 80 years or older who underwent a urogynecologic procedure at a tertiary care specialty practice between 2006 and 2014. Subjects were identified by their Current Procedural Terminology codes and the electronic medical record was queried for demographic and perioperative data. Functional status was recorded using data from the preoperative anesthesia assessment, and included the functional status score (range, 1-4) and a functional capacity evaluation (metabolic equivalents [METs, range, 1 to 8+]). One hundred sixty-four women aged 80 years or older underwent a urogynecologic procedure during the study period. Mean age was 83 years (±3; range, 80-95 years). The median functional status was 2 (1-4) and median functional capacity was 5.5 METs (1.75-8.0). The overall postoperative adverse event rate was 18.3%; the incidence of serious events was 7.8%. Most serious events were associated with preexisting medical conditions. Presence of 3 or more comorbid conditions was associated with a higher risk of postoperative readmission, need for transfusion and deep vein thrombosis/pulmonary embolism. Preoperative functional status and functional capacity were not associated with postoperative adverse events. Patients with METs scores of 4.5 or less were more likely to need home services or a skilled nursing facility (SNF) postoperatively compared with patients with higher scores (28.9% vs 6.7%, P < 0.0001; odds ratio, 4.3; 95% confidence interval, 1.6-11.9). Dementia was also associated with SNF admission (36.3% vs 10%; P = 0.01; odds ratio, 3.6; 95% confidence interval, 1.1-12.8). The incidence of serious postoperative adverse events is low in very elderly patients undergoing urogynecologic procedures. Dementia and poor functional capacity appear to be associated with a higher need for postoperative home services or SNF admission.

Epidemiology, microbiology, clinical characteristics, and outcomes of candidemia in internal medicine wards—a retrospective study

The clinical characteristics of internal medicine ward (IMW) patients with candidemia are unclear. The aim of this study was to define the clinical characteristics of candidemic IMW patients and to study the incidence, species distribution, and outcomes of these patients compared to surgical and intensive care unit (ICU) candidemic patients. A retrospective cohort of candidemic patients in IMWs, general surgery wards, and an ICU at Beilinson Hospital during the period 2007-2014 was analyzed. A total of 118 patients with candidemia were identified in six IMWs, two general surgery wards, and one ICU in the hospital. Candida albicans was the leading causative agent (41.1%). Higher proportions of Candida parapsilosis and Candida tropicalis isolates were observed in the IMW patients. IMW patients were significantly older, with poorer functional capacity, and had more frequently been exposed to antibiotic therapy within 90 days, in particular β-lactam-β-lactamase inhibitor combinations and cephalosporins. At onset of candidemia, a significantly lower number of IMW patients were mechanically ventilated (p<0.01); these patients did not have central line catheters comparable to ICU and surgical patients (p<0.001). They were less likely to receive adequate antifungal therapy within 48h, and this was the only significant predictor of survival in these patients (p=0.028): hazard ratio 3.7 (95% confidence interval 1.14-12.5) for therapy delayed to >48h. IMW candidemic patients account for a substantial proportion of candidemia cases and have unique characteristics and high mortality rates.

The incidence, risk factors, and outcomes associated with late right-sided heart failure in patients supported with an axial-flow left ventricular assist device

Early right-sided heart failure (RHF) after left ventricular assist device (LVAD) implantation is associated with increased mortality, but little is known about patients who develop late RHF (LRHF). We evaluated the incidence, risk factors, and clinical impact of LRHF in patients supported by axial-flow LVADs. Data were analyzed from 537 patients enrolled in the HeartMate II (HM II; Thoratec/St. Jude) destination therapy clinical trial. LRHF was defined as the development of clinical RHF accompanied by the need for inotropic support occurring more than 30 days after discharge from the index LVAD implant hospitalization. Clinical variables, quality of life, rehospitalizations, and survival were compared between patients with and without LRHF. LRHF developed in 41 patients (8%), with a median time to LRHF of 480 days. A higher preoperative blood urea nitrogen and increased central venous pressure-to-pulmonary capillary wedge pressure ratio were independent predictors of LRHF. The Michigan and HMII RHF risk scores were both associated with an increased likelihood of LRHF (p < 0.05). Patients with LRHF had worse quality of life according to the Kansas City Cardiomyopathy Questionnaire (61 ± 26 vs 70 ± 21; p < 0.05), poorer functional capacity by 6-minute walk distance (275 ± 189 m vs 312 ± 216 m; p < 0.05), and more rehospitalizations (6 vs 3; p < 0.001). LRHF was associated with decreased survival (p < 0.001). LRHF is an important complication in patients with LVADs and is associated with worse quality of life, reduced functional capacity, more frequent hospitalizations, and worse survival compared with those without LRHF.

Patients with poor baseline walking capacity are most likely to improve their functional status with multimodal prehabilitation

Evidence suggests that multimodal prehabilitation programs comprising interventions directed at physical activity, nutrition, and anxiety coping can improve functional recovery after colorectal cancer operations; however, such programs may be more clinically meaningful and cost-effective if targeted to specific subgroups. This study aimed to estimate the extent to which patients with poor baseline functional capacity improve their functional capacity. Data for 106 participants enrolled in a multimodal, prehabilitation program before colorectal operations were analyzed. Low baseline functional capacity was defined as a 6-minute walking test distance (6MWD) of less than 400m. Participants were categorized as higher fitness (6MWD≥400m, n=70) or lower fitness (6MWD <400m, n=36). Changes in 6MWD over the preoperative period, and 4weeks and 8weeks after the operation were compared between groups. Secondary outcomes included patient-reported physical activity and health status, postoperative complications, duration of hospital stay, and readmissions. Less-fit patients were then compared with subjects in the rehabilitation arm of the original studies who had a baseline 6MWD <400m. Participants with lower baseline fitness had greater improvements in functional walking capacity with prehabilitation compared to patients with higher fitness (+46.5 [standard deviation 53.8] m vs +22.6 [standard deviation 41.8] m, P=.012). At 4weeks postoperatively, patients with lower baseline fitness were more likely to be recovered to their baseline 6MWD than those with higher fitness. (74% vs 50%, P=.029). There were no differences in secondary outcome. Less-fit patients had a greater improvement through all the preoperative period compared to the control group. Patients with lower baseline walking capacity are more likely to experience meaningful improvement in physical function from prehabilitation before and after a colorectal cancer operation.

Japanese perceptions of societal vulnerability to disasters during population ageing: Constitution of a new scale and initial findings

This research describes the development and initial results from the Perceptions of Ageing and Disaster Vulnerability Scale (PADVS) that was designed to explore perceptions of vulnerability to disasters in the context of population ageing. Few Japanese studies have explored perceptions of disaster-related vulnerability in Japan, although this issue is growing in importance due to the acceleration of population ageing and the recurrence of large-scale disasters.Following pre-testing, the PADVS was administered with 172 health students and professionals from three Japanese regions in 2016. The reliability and validity of the PADVS were assessed using commonly employed psychometric evaluation techniques, including assessment of face and content validity, internal consistency, item-total correlations, inter-item correlations, and factorial validity. Descriptive statistics were used to ascertain total, subscale, and item scores.With one item removed due to poor fit, a 13-item version of PADVS exhibited acceptable reliability (α=.87) and validity. The scale fit a four-component solution following principal components analysis, with four indicative subscales. Results of PADVS completion showed clear respondent concerns about social isolation and lack of support networks, and poor functional capacity among older adult populations.The PADVS provides a reliable and valid measure for researchers to assess perceptions of societal vulnerability related to disasters in the context of population ageing. Preparations for recurring disasters should focus on improving supportive social network connections among older adults and providing intervention measures to improve physical, cognitive, and emotional health for older adults, particularly those who live alone in the community.

Psychological disorders in adults with inherited cardiomyopathies and Takotsubo syndrome.

We performed a narrative review about psychological disorders in adults with Takotsubo syndrome and inherited cardiomyopathies. Through the electronic database PubMed and PsycINFO we searched all relevant related manuscripts published between 2000 and 2015. We found twelve studies that explore psychological disorders in Takotsubo syndrome and eight about inherited cardiomyopathies: five enrolled patients with hypertrophic cardiomyopathy, two dilated cardiomyopathy, and one arrhythmogenic right ventricular cardiomyopathy. All papers reported the presence of psychological disorders. In Takotsubo syndrome, depression fluctuates between 20.5 and 48% and anxiety was present among 26 and 56%. A study reported that anxiety increases the probability of developing Takotsubo syndrome. In dilated cardiomyopathy, anxiety was present in 50% and depression in 22%. In arrhythmogenic right ventricular cardiomyopathy, younger age, poorer functional capacity and having experienced at least one implantable cardioverter defibrillator shock, were significant independent predictors of both device-specific and generalized anxiety. In hypertrophic cardiomyopathy, anxiety and depression were present in 45.2% and 17.9%, respectively. Thirty seven percent met diagnostic criteria for anxiety disorders and 21% for mood disorders. Nearby half hypertrophic cardiomyopathy patients report triggering of chest pain, dyspnea, and dizziness by emotional stress. Due to the small number of studies, conclusions are limited. However, we discuss some results.

Higher Daily Physical Activities Continue to Preserve Muscle Strength After Mid-Life, But Not Muscle Mass After Age of 75.

The objective of this study is to explore the impact of aging and daily physical activities (PA) on muscle mass and muscle strength among community-dwelling people in Taiwan.The design is a cross-sectional study. Setting is a population-based community study.One thousand eight hundred thirty-nine community-dwelling people aged 50 years and older in Taiwan participated in the study.Measurements include demographic characteristics, Charlson Comorbidity Index (CCI) for multimorbidity, mini-nutritional assessment (MNA) for nutritional evaluation, functional autonomy measurement system (SMAF) for functional capacity, Chinese version mini mental state examination (MMSE), 5-item Taiwan Geriatric Depression Scale (TGDS-5), Chinese version of International Physical Activity Questionnaire (IPAQ), height-adjusted skeletal muscle index (SMI) by dual-energy X-ray absorptiometry, handgrip strength, timed 6-m walking test for usual gait speed. Laboratory measurements include testosterone, sex-hormone binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEA-S), insulin-like growth factor-1 (IGF-1), high-sensitivity C-reactive protein (hsCRP), 25-OH vitamin D, and insulin resistance.After adjusted for age, the lowest PA tertile was associated with multimorbidity, poorer functional capacity and nutritional status, more depressive symptoms, lower SMI and lower handgrip strength, and lower free androgen index (FAI) in men. The negative association between PA and low SMI was more significant among subjects aged younger than 65 and the association decreased with older age. For subjects aged younger than 65, moderate daily PA (Q2) group had lower risk of low SMI compared with Q1 participants (OR: 0.62, 95% CI = 0.39–0.98, P = 0.040). For muscle strength, higher daily PA was associated with lower risk of low handgrip strength after age of 65 and the effect was dose-dependent. The effect was attenuated by potential confounders during age 65 to 74, while after age 75, the result was almost unchanged in fully adjusted model (OR = 0.37, 95% CI = 0.18–0.79, P = 0.010).Older age may attenuate the protective effects of higher daily PA on preventing muscle loss, but higher daily PA continues to preserve muscle strength at different age groups, even after the age of 75. The prognostic role of daily PA may be mediated by muscle strength instead of muscle mass among people aged 75 years and older.

Poorer limb salvage in African American men with chronic limb ischemia is due to advanced clinical stage and higher anatomic complexity at presentation

African Americans (AAs) with symptomatic peripheral arterial disease (PAD) have been reported to have fewer revascularization attempts and poorer patency and limb salvage (LS) rates than Caucasians (CAUs). This study compared the outcomes between AA and CAU men with chronic limb ischemia. All AA and CAU men who underwent treatment for symptomatic PAD between November 1, 2003, and May 31, 2012, were included. Patency rates, LS, major adverse cardiovascular and limb events, amputation-free survival, and survival were compared before and after propensity score matching and with multivariate (Cox regression) analysis. Of the 834 men (1062 limbs), 107 were AA (137 limbs) and 727 were CAU (925 limbs). AAs were more likely to have insulin-dependent diabetes mellitus, hypertension, dialysis dependence, lower albumin levels, and critical limb ischemia (73% vs 61%; P= .006), whereas CAUs had more coronary artery disease, dyslipidemia, and chronic obstructive pulmonary disease. In patients with critical limb ischemia, primary amputation rates (10.9% vs 7.2%; P= .209) were similar between groups; however, infrapopliteal interventions were more frequent in AAs (62.6% vs 44.3%; P= .004). Perioperative morbidity and mortality rates were similar. Mean follow-up was 38.5± 28.9months (range, 0-119months). Patency rates, major adverse limb and cardiovascular events, amputation-free survival, and survival were similar in AAs and CAUs; however, the LS rate was significantly lower in AA (73%± 6% vs 83%± 2%; P= .048), mainly due to the difference in the endovascular-treated group (5-year LS, 69%± 7% in AAs vs 84%± 2% in CAUs; P=.025). All outcomes were similar in propensity score-matched cohorts. In multivariate analysis, insulin-dependent diabetes mellitus, gangrene, poor functional capacity, dialysis-dependence, and need for infrapopliteal revascularization were independently associated with limb loss, whereas race was not. AA men with symptomatic PAD were found to have lower LS rates than CAUs. However, this was likely dueto presenting with advanced ischemia or with poor prognostic factors that are independently associated with limb loss.

Heart Failure Resulting From Age-Related Cardiac Amyloid Disease Associated With Wild-Type Transthyretin: A Prospective, Observational Cohort Study.

Heart failure caused by wild-type transthyretin amyloidosis (ATTRwt) is an underappreciated cause of morbidity and mortality in the aging population. The aims of this study were to examine features of disease and to characterize outcomes in a large ATTRwt cohort. Over 20 years, 121 patients with ATTRwt were enrolled in a prospective, observational study. Median age at enrollment was 75.6 years (range, 62.6-87.8 years); 97% of patients were white. The median survival, measured from biopsy diagnosis, was 46.69 months (95% confidence interval, 41.95-56.77); 78% of deaths were attributable to cardiac causes. By Kaplan-Meier analysis, 5-year survival was 35.7% (95% confidence interval, 25-46). Impaired functional capacity (mean Vo2max, 13.5 mL·kg(-1)·min(-1)) and atrial fibrillation (67%) were common clinical features. Multivariate predictors of reduced survival were elevated serum brain natriuretic peptide (482 ± 337 pg/mL) and uric acid (8.2 ± 2.6 mg/dL), decreased left ventricular ejection fraction (50% median; range, 10%-70%), and increased relative wall thickness (0.75 ± 0.19). In this series of patients with biopsy-proven ATTRwt, poor functional capacity and atrial arrhythmias were common clinical features. Elevated brain natriuretic peptide and uric acid, decreased left ventricular ejection fraction, and increased relative wall thickness were associated with limited survival of only 35.7% at 5 years for the group as a whole. These data establish the natural history of ATTRwt, provide statistical basis for the design of future interventional clinical trials, and highlight the need for more sensitive diagnostic tests and disease-specific treatments for this disease.

AB0 blood types: impact on development of prosthetic mechanical valve thrombosis.

Objective:The non-O alleles of the ABO genotype have been associated with an increased risk of thrombosis. We aimed to assess the association between blood group status and prosthetic valve thrombosis.Methods:The association between AB0 blood group status and prosthetic valve thrombosis was assessed in this retrospective study. Transesophageal echocardiography was performed in 149 patients with a diagnosis of prosthetic valve thrombosis and in 192 control subjects.Results:Non-0 blood group type (p<0.001), presence of NYHA class III-IV status (p<0.001), and central nervous system (p<0.001) and non-central nervous system (p<0.001) emboli were significantly more prevalent in prosthetic valve thrombosis patients than in the control subjects. The incidence of ineffective anticoagulation was higher in patients with prosthetic valve thrombosis than in controls (p<0.001), as was the presence of moderate to severe left atrial spontaneous echo contrast (p<0.001). The non-0 blood prosthetic valve thrombosis subgroup had a higher incidence of obstructive thrombi and central nervous system thrombotic events than having 0 blood prosthetic valve thrombosis subgroup. Non-0 blood group, ineffective anticoagulation, left atrial spontaneous echo contrast, and a poor NYHA functional capacity were identified to be the predictors of prosthetic valve thrombosis.Conclusion:Our data demonstrate that patients with non-0 compared with 0 blood groups have higher incidence of prosthetic valve thrombosis and central nervous system embolism and similar rates of non-central nervous system embolism at presentation compared with 0 blood group type. Thus, non-O blood group may be a risk factor that may be prone to the development of prosthetic valve thrombosis in patients with prosthetic heart valves.

Effects of neuromuscular reeducation on hip mechanics and functional performance in patients after total hip arthroplasty: A case series

BackgroundFollowing total hip arthroplasty, patients demonstrate compensatory movement strategies during activities of daily living such as walking and stair climbing. Movement compensations are important markers of functional decline in older adults and are related to poor functional capacity. Despite increased utilization of hip arthroplasty, persistent movement compensation, and functional performance deficits, no consensus on postoperative rehabilitation exists. Neuromuscular reeducation techniques offer a strategy to improve movement quality by emphasizing hip abductor performance and pelvic stability. This case series illustrates changes in movement strategy around the hip in response to targeted neuromuscular reeducation techniques after hip arthroplasty. MethodsFive participants received an 8-week exercise program following total hip arthroplasty, emphasizing targeted neuromuscular reeducation techniques hallmarked by specific, weight-bearing exercise to improve hip abductor performance and pelvic stability. Five additional participants were supervised and followed for comparison. FindingsParticipants in the neuromuscular reeducation program improved their internal hip abductor moments and vertical ground reaction forces during walking and stair climbing. They also improved their functional performance and hip abductor strength outcomes. InterpretationTargeted neuromuscular reeducation techniques after total hip arthroplasty provided a positive effect on biomechanical outcomes, functional performance, and muscle strength. Through focused use of the hip abductor muscles, increased internal hip abductor moments were observed. This intervention potentially promotes pelvic stability, and may contribute to improved performance on tasks such as stair climbing, fast walking, and balance. The results suggest that neuromuscular reeducation offers a unique effect on movement strategy and function for patients following total hip arthroplasty.

Stroke in atrial fibrillation and improving the identification of ‘high‐risk’ patients: the crossroads of immunity and thrombosis

Stroke in atrial fibrillation and improving the identification of ‘high‐risk’ patients: the crossroads of immunity and thrombosis