Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this c... more Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this cross-sectional descriptive study was to describe the prevalence of EDS and factors associated with it in HF. A secondary purpose was to explore the correlates of fatigue. We enrolled a consecutive sample of 280 adults with a confirmed diagnosis of chronic HF from three outpatient settings in the northeastern US. Patients with major depressive illness were excluded. Clinical, sociodemographic, behavioral, and perceptual factors were explored as possible correlates of EDS. Using an Epworth Sleepiness Scale score >10, the prevalence of EDS was 23.6%. Significant determinants of EDS were worse sleep quality (p=0.048), worse functional class (p=0.004), not taking a diuretic (p=0.005), and lack of physical activity (p=0.04). Only sleep quality was
Background: A relationship between excessive daytime sleepiness (EDS) and poor treatment adherenc... more Background: A relationship between excessive daytime sleepiness (EDS) and poor treatment adherence has been suspected but not confirmed. We hypothesized that medication adherence would be poorer in adults with heart failure (HF) and EDS and that cognitive status would be the mechanism of effect. Methods: A sample of 280 adults with chronic HF was enrolled into a prospective cohort comparison study. We identified a cohort with EDS and a control group without EDS and further divided both groups into those with and without mild cognitive decline. Data on medication adherence was obtained at baseline, 3-and 6-months using the Basel Assessment of Adherence Scale (BAASIS). Regression analysis was used to clarify the contribution of EDS and cognition to medication adherence and to assess relationships over six months after adjusting for age, enrollment site, gender, race, functional class, depression, and premorbid intellect. Results: At baseline, 62% of subjects were nonadherent to their medication regime. Nonadherence was significantly more common in those with EDS, regardless of cognitive status (p=0.035). The odds of nonadherence increased by 11% for each unit increase in EDS (AOR=1.11, 95% CI=1.05-1.19, p=0.001). In longitudinal models there was a 10% increase in the odds of nonadherence for each unit increase in EDS (p=0.008). The only cognition measure significantly associated with medication adherence was attention (p=0.047). Conclusion: Adults with HF and EDS are more likely to have problems adhering to their medication regimen than those without EDS, regardless of their cognitive status. Identifying and correcting factors that interfere with sleep may improve medication adherence.
Background-Sleep dysfunction contributes to poor quality of life in adults with heart failure (HF... more Background-Sleep dysfunction contributes to poor quality of life in adults with heart failure (HF). The purpose of this study was to identify factors associated with sleep dysfunction that may be modifiable. Methods-Data were collected from 266 subjects enrolled from three sites in the U.S. Sleep dysfunction was measured over the past month with the Pittsburgh Sleep Quality Index, using a score >10 to indicate sleep dysfunction. Potentially modifiable clinical, behavioral, and psychological factors thought to be associated with sleep dysfunction were analyzed with hierarchical logistic regression analysis. Results-When covariates of age, gender, race, data collection site, and New York Heart Association (NYHA) functional class were entered on the first step, only NYHA was a significant correlate of sleep dysfunction. When the clinical, behavioral, and psychological factors were entered, correlates of sleep dysfunction were the number of drugs known to cause daytime somnolence (OR = 2.08), depression (OR = 1.83), worse overall perceived health (OR = 1.64), and better sleep hygiene (OR = 1.40). Although most (54%) subjects had sleep disordered breathing (SDB), SDB was not a significant predictor of sleep dysfunction.
Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this c... more Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this cross-sectional descriptive study was to describe the prevalence of EDS and factors associated with it in HF. A secondary purpose was to explore the correlates of fatigue. We enrolled a consecutive sample of 280 adults with a confirmed diagnosis of chronic HF from three outpatient settings in the northeastern United States. Patients with major depressive illness were excluded. Clinical, sociodemographic, behavioral, and perceptual factors were explored as possible correlates of EDS. Using an Epworth Sleepiness Scale score > 10, the prevalence of EDS was 23.6%. Significant determinants of EDS were worse sleep quality ( p = .048), worse functional class ( p = .004), not taking a diuretic ( p = .005), and lack of physical activity ( p = .04). Only sleep quality was associated with fatigue ( p < .001). Sleep-disordered breathing was not significantly associated with EDS or with fatigue....
Antibody-mediated rejection (AMR) (humoral rejection) of cardiac allografts remains difficult to ... more Antibody-mediated rejection (AMR) (humoral rejection) of cardiac allografts remains difficult to diagnose and treat. Interest in AMR of cardiac allografts has increased over the last decade as it has become apparent that untreated humoral rejection threatens graft and patient survival. An international and multidisciplinary consensus group has formulated guidelines for the diagnosis and treatment of AMR and established that identification of circulating or donor-specific antibodies is not required and that asymptomatic AMR, that is, biopsy-proven AMR without cardiac dysfunction is a real entity with worsened prognosis. Strict criteria for the diagnosis of cardiac AMR have not been firmly established, although the diagnosis relies heavily on tissue pathological findings. Therapy remains largely empirical. We review an unfortunate experience with one of our patients and summarize recommended criteria for the diagnosis of AMR and potential treatment schemes with a focus on current limi...
Background: Cardiac fibrosis is a characteristic feature of the failing heart for which there is ... more Background: Cardiac fibrosis is a characteristic feature of the failing heart for which there is an unmet need of fibro-inhibiting therapies targeting heart failure (HF). C-type natriuretic peptide (CNP), a human endothelial derived 22 amino acid (AA) peptide, is a guanylyl cyclase B (GC-B) activator that mediates potent anti-fibrotic actions via its second messenger, cGMP. However, the endogenous anti-fibrotic actions of CNP are limited, in part, due to its rapid metabolic clearance by the clearance receptor (NPRC), which has been reported to be up regulated in HF patients. Considering the fibrosuppressing properties of GC-B activation, we engineered a novel 53 AA peptide (C53) based upon the CNP and proCNP sequence with the goal of advancing C53's therapeutic potential including reduced NPRC binding. Hypothesis: We hypothesized C53 would have enhanced cGMP generating actions in vivo due to reduced NPRC binding compared to CNP and C53 would activate cGMP in human cardiac fibroblasts (hCFs). Methods: Therapeutic dose of CNP, equimolar dose of C53 and vehicle were IV infused into normal anesthetized rats (n = 12) and in vivo CNP and cGMP levels were assessed. NPRC binding with C53 and CNP were assessed using a modified AlphaScreen luminescent proximity assay (ALPA). In vitro cGMP activating property of C53 (10 −8 M and 10 −6 M) compared to no treatment in hCFs was assessed. Data are mean ± SE and significance was achieved with P < .05. Results: In vivo, C53 significantly increased plasma and urinary cGMP compared to equimolar CNP and vehicle (P < .05), which correlated with higher plasma CNP levels with C53 IV infusion (P < .05). Binding studies using the ALPA demonstrated that C53 had reduced binding to NPRC compared to CNP. In hCFs, C53 generated cGMP at 10 −8 M and markedly activated cGMP at 10 −6 M compared to no treatment (no treatment: 0.00 ± 0.00; 10 −8 M: 0.17 ± 0.03; 10 −6 M: 1.79 ± 0.02, pmol/well, P < .05). Conclusion: We report a newly engineered CNPbased peptide, C53, has cGMP activating actions in hCFs and has superior in vivo cGMP generation than CNP which may, in part, be related to reduced binding to the metabolic clearance receptor NPRC. These studies suggest that C53 may be a novel therapeutic strategy for the prevention and treatment of cardiac fibrosis in HF and further investigations are warranted.
Obstructive sleep apnea (OSA) is a form of sleep disordered breathing in which pharyngeal muscle ... more Obstructive sleep apnea (OSA) is a form of sleep disordered breathing in which pharyngeal muscle relaxation leads to recurrent nighttime apneas and hypopneas that, through increased afterload, intermittent hypoxia, and excess sympathetic activity, weaken the already failing heart. This review presents the current evidence regarding the complex relationship between OSA and heart failure (HF), including support for OSA as both a cause and consequence of HF. The impact of OSA on other cardiovascular diseases, such as hypertension, ischemic heart disease and arrhythmias, as they relate to HF development or exacerbation, also are reviewed.
Welcome to the fourth issue of Sleep Research Review. One of the studies selected for this issue ... more Welcome to the fourth issue of Sleep Research Review. One of the studies selected for this issue reports that treatment with positive airway pressure reduces 30-day readmission rates and emergency department visits in cardiac patients who are diagnosed with obstructive sleep apnoea. The study authors comment that reducing hospital admission rates for cardiac patients is essential for providing cost-effective care. Another study reports improvement in patients suffering from restless legs syndrome occurring with iron deficiency anaemia after they received treatment with intravenous iron therapy. This effect was sustained for more than 6 months in several of the patients. Best wishes for the festive season to all of our readers and I look forward to your comments and feedback throughout the coming year.
Chronic heart failure (CHF) 105 cardiovascular mortality were seen in any age or LVEF subgroup. G... more Chronic heart failure (CHF) 105 cardiovascular mortality were seen in any age or LVEF subgroup. Geographical location was not associated with any apparent impact of DMPs on the primary outcomes. Conclusion: This systematic review and subgroup meta-analysis suggests that patient age and LVEF are associated with the impact of DMPs in HF.
Heart failure is a chronic, progressive disease. Despite advances in the management of heart fail... more Heart failure is a chronic, progressive disease. Despite advances in the management of heart failure over the past 30 years, many patients will progress to an advanced stage of the disease that negatively impacts their quality of life and ultimately leads to death. As our success in managing acute coronary syndromes and sudden cardiac death has improved, more patients are surviving to end-stage heart failure. Understanding the etiology of the progression and eliminating other causes of dyspnea or edema is the first step in the management of this challenging population. For younger patients without serious comorbidities, cardiac transplantation is an alternative that may extend the quantity and improve the quality of life. For those who are not transplant candidates, there are limited options, and often the focus becomes one of maintaining function and controlling symptoms, occasionally at the expense of mortality. In truly refractory heart failure, hospice care may be appropriate in order to maintain comfort and dignity.
Journal of the American College of Cardiology, Oct 1, 2009
Over the past 15 years, the association of sleep apnea and serious medical consequences has slowl... more Over the past 15 years, the association of sleep apnea and serious medical consequences has slowly entered mainstream medicine. From a noisy and almost comical condition to one that is now recognized to be associated with serious morbidity and mortality, investigators around the world are studying the complex relationships between sleep and the neurologic, pulmonary, endocrine, and cardiovascular systems. As the evidence has mounted, screening and treatment of sleep apnea has been incorporated into clinical practice guidelines and reports for several serious medical conditions including, among others, hypertension (Joint National Committee 7) (1), heart failure (American College of Cardiology/American Heart Association [ACC/AHA]) (2), pulmonary arterial hypertension (ACC/AHA) (3), and type 2 diabetes mellitus (International Diabetes Federation) (4). This effort has culminated in an ACC/AHA scientific statement focused exclusively on sleep apnea and cardiovascular disease. This statement reviews the known mechanisms as well as the association of various forms of sleep apnea with hypertension, heart failure, stroke, arrhythmias, myocardial infarction and ischemia, pulmonary arterial hypertension, and end-stage renal disease. It concludes with a call for more study to understand mechanisms, associations, and the impact of treatment of sleep apnea on patients with and at risk for cardiovascular disease (5).
Journal of the American College of Cardiology, Mar 1, 2015
Background: Interventions designed to improve appropriate use of cardiac stress tests (CST) have ... more Background: Interventions designed to improve appropriate use of cardiac stress tests (CST) have focused primarily or exclusively on ambulatory patients. We designed a computerized order entry tool (OET) to facilitate more appropriate use of CST in hospitalized patients. methods: The OET included prompts to suggest exercise ECG testing, rather than CST with imaging, for patients who were at low risk, and links to relevant guidelines. We applied appropriate use criteria before (PRE) and after (POST) implementation of the OET. results: We studied 941 patients (478 PRE and 463 POST) over 1.5 years. Age (61 years) and gender (45% female) were similar PRE and POST. Known coronary disease was higher in the PRE group (30% vs. 23%, p=0.02). Risk factors for coronary disease were similar (average 2 risk factors per patient). About two-thirds of CST were for chest pain or ischemic equivalent and 18% were pre-operative. Of the patients with chest pain, 76% were low risk (TIMI score ≤2) and 28% were very low risk (TIMI score 0). The OET had a significant impact. Only 4% of CST were exercise ECG tests PRE, compared to 15% POST (p<0.001). The overall rate of inappropriate tests did not change significantly (12% PRE vs. 11% POST, p=0.54). However, of the patients with low risk chest pain, the rate of exercise ECG testing did increase (4% PRE vs. 17% POST, p<0.001), and inappropriate testing improved (2% PRE vs. 0% POST, p=0.05). Among very low risk patients there were similar improvements in use of exercise ECG tests (7% vs. 25%, p<0.001) and inappropriate use (3% vs. 0%, p=0.25). Most inappropriate imaging CST were pre-operative (88% vs. 11% of other tests, p<0.001). Inappropriate CST patients were more often male (66% vs. 54%, p=0.02) and white (77% vs. 44%, p<0.001), with lower rates of cardiac risk factors and less known coronary disease. conclusion: Our novel OET for CST in hospitalized patients increased the usage of exercise ECG testing, particularly among low risk chest pain patients. While the overall rate of inappropriate use did not change, it was reduced in low risk chest pain patients. Very few imaging CST were inappropriate in chest pain patients, which may reflect a limitation of the current appropriate use criteria.
Background: Interventions designed to improve appropriate use of cardiac stress tests (CST) have ... more Background: Interventions designed to improve appropriate use of cardiac stress tests (CST) have focused primarily or exclusively on ambulatory patients. We designed a computerized order entry tool (OET) to facilitate more appropriate use of CST in hospitalized patients. methods: The OET included prompts to suggest exercise ECG testing, rather than CST with imaging, for patients who were at low risk, and links to relevant guidelines. We applied appropriate use criteria before (PRE) and after (POST) implementation of the OET. results: We studied 941 patients (478 PRE and 463 POST) over 1.5 years. Age (61 years) and gender (45% female) were similar PRE and POST. Known coronary disease was higher in the PRE group (30% vs. 23%, p=0.02). Risk factors for coronary disease were similar (average 2 risk factors per patient). About two-thirds of CST were for chest pain or ischemic equivalent and 18% were pre-operative. Of the patients with chest pain, 76% were low risk (TIMI score ≤2) and 28% were very low risk (TIMI score 0). The OET had a significant impact. Only 4% of CST were exercise ECG tests PRE, compared to 15% POST (p<0.001). The overall rate of inappropriate tests did not change significantly (12% PRE vs. 11% POST, p=0.54). However, of the patients with low risk chest pain, the rate of exercise ECG testing did increase (4% PRE vs. 17% POST, p<0.001), and inappropriate testing improved (2% PRE vs. 0% POST, p=0.05). Among very low risk patients there were similar improvements in use of exercise ECG tests (7% vs. 25%, p<0.001) and inappropriate use (3% vs. 0%, p=0.25). Most inappropriate imaging CST were pre-operative (88% vs. 11% of other tests, p<0.001). Inappropriate CST patients were more often male (66% vs. 54%, p=0.02) and white (77% vs. 44%, p<0.001), with lower rates of cardiac risk factors and less known coronary disease. conclusion: Our novel OET for CST in hospitalized patients increased the usage of exercise ECG testing, particularly among low risk chest pain patients. While the overall rate of inappropriate use did not change, it was reduced in low risk chest pain patients. Very few imaging CST were inappropriate in chest pain patients, which may reflect a limitation of the current appropriate use criteria.
Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this c... more Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this cross-sectional descriptive study was to describe the prevalence of EDS and factors associated with it in HF. A secondary purpose was to explore the correlates of fatigue. We enrolled a consecutive sample of 280 adults with a confirmed diagnosis of chronic HF from three outpatient settings in the northeastern US. Patients with major depressive illness were excluded. Clinical, sociodemographic, behavioral, and perceptual factors were explored as possible correlates of EDS. Using an Epworth Sleepiness Scale score >10, the prevalence of EDS was 23.6%. Significant determinants of EDS were worse sleep quality (p=0.048), worse functional class (p=0.004), not taking a diuretic (p=0.005), and lack of physical activity (p=0.04). Only sleep quality was
Background: A relationship between excessive daytime sleepiness (EDS) and poor treatment adherenc... more Background: A relationship between excessive daytime sleepiness (EDS) and poor treatment adherence has been suspected but not confirmed. We hypothesized that medication adherence would be poorer in adults with heart failure (HF) and EDS and that cognitive status would be the mechanism of effect. Methods: A sample of 280 adults with chronic HF was enrolled into a prospective cohort comparison study. We identified a cohort with EDS and a control group without EDS and further divided both groups into those with and without mild cognitive decline. Data on medication adherence was obtained at baseline, 3-and 6-months using the Basel Assessment of Adherence Scale (BAASIS). Regression analysis was used to clarify the contribution of EDS and cognition to medication adherence and to assess relationships over six months after adjusting for age, enrollment site, gender, race, functional class, depression, and premorbid intellect. Results: At baseline, 62% of subjects were nonadherent to their medication regime. Nonadherence was significantly more common in those with EDS, regardless of cognitive status (p=0.035). The odds of nonadherence increased by 11% for each unit increase in EDS (AOR=1.11, 95% CI=1.05-1.19, p=0.001). In longitudinal models there was a 10% increase in the odds of nonadherence for each unit increase in EDS (p=0.008). The only cognition measure significantly associated with medication adherence was attention (p=0.047). Conclusion: Adults with HF and EDS are more likely to have problems adhering to their medication regimen than those without EDS, regardless of their cognitive status. Identifying and correcting factors that interfere with sleep may improve medication adherence.
Background-Sleep dysfunction contributes to poor quality of life in adults with heart failure (HF... more Background-Sleep dysfunction contributes to poor quality of life in adults with heart failure (HF). The purpose of this study was to identify factors associated with sleep dysfunction that may be modifiable. Methods-Data were collected from 266 subjects enrolled from three sites in the U.S. Sleep dysfunction was measured over the past month with the Pittsburgh Sleep Quality Index, using a score >10 to indicate sleep dysfunction. Potentially modifiable clinical, behavioral, and psychological factors thought to be associated with sleep dysfunction were analyzed with hierarchical logistic regression analysis. Results-When covariates of age, gender, race, data collection site, and New York Heart Association (NYHA) functional class were entered on the first step, only NYHA was a significant correlate of sleep dysfunction. When the clinical, behavioral, and psychological factors were entered, correlates of sleep dysfunction were the number of drugs known to cause daytime somnolence (OR = 2.08), depression (OR = 1.83), worse overall perceived health (OR = 1.64), and better sleep hygiene (OR = 1.40). Although most (54%) subjects had sleep disordered breathing (SDB), SDB was not a significant predictor of sleep dysfunction.
Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this c... more Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this cross-sectional descriptive study was to describe the prevalence of EDS and factors associated with it in HF. A secondary purpose was to explore the correlates of fatigue. We enrolled a consecutive sample of 280 adults with a confirmed diagnosis of chronic HF from three outpatient settings in the northeastern United States. Patients with major depressive illness were excluded. Clinical, sociodemographic, behavioral, and perceptual factors were explored as possible correlates of EDS. Using an Epworth Sleepiness Scale score > 10, the prevalence of EDS was 23.6%. Significant determinants of EDS were worse sleep quality ( p = .048), worse functional class ( p = .004), not taking a diuretic ( p = .005), and lack of physical activity ( p = .04). Only sleep quality was associated with fatigue ( p < .001). Sleep-disordered breathing was not significantly associated with EDS or with fatigue....
Antibody-mediated rejection (AMR) (humoral rejection) of cardiac allografts remains difficult to ... more Antibody-mediated rejection (AMR) (humoral rejection) of cardiac allografts remains difficult to diagnose and treat. Interest in AMR of cardiac allografts has increased over the last decade as it has become apparent that untreated humoral rejection threatens graft and patient survival. An international and multidisciplinary consensus group has formulated guidelines for the diagnosis and treatment of AMR and established that identification of circulating or donor-specific antibodies is not required and that asymptomatic AMR, that is, biopsy-proven AMR without cardiac dysfunction is a real entity with worsened prognosis. Strict criteria for the diagnosis of cardiac AMR have not been firmly established, although the diagnosis relies heavily on tissue pathological findings. Therapy remains largely empirical. We review an unfortunate experience with one of our patients and summarize recommended criteria for the diagnosis of AMR and potential treatment schemes with a focus on current limi...
Background: Cardiac fibrosis is a characteristic feature of the failing heart for which there is ... more Background: Cardiac fibrosis is a characteristic feature of the failing heart for which there is an unmet need of fibro-inhibiting therapies targeting heart failure (HF). C-type natriuretic peptide (CNP), a human endothelial derived 22 amino acid (AA) peptide, is a guanylyl cyclase B (GC-B) activator that mediates potent anti-fibrotic actions via its second messenger, cGMP. However, the endogenous anti-fibrotic actions of CNP are limited, in part, due to its rapid metabolic clearance by the clearance receptor (NPRC), which has been reported to be up regulated in HF patients. Considering the fibrosuppressing properties of GC-B activation, we engineered a novel 53 AA peptide (C53) based upon the CNP and proCNP sequence with the goal of advancing C53's therapeutic potential including reduced NPRC binding. Hypothesis: We hypothesized C53 would have enhanced cGMP generating actions in vivo due to reduced NPRC binding compared to CNP and C53 would activate cGMP in human cardiac fibroblasts (hCFs). Methods: Therapeutic dose of CNP, equimolar dose of C53 and vehicle were IV infused into normal anesthetized rats (n = 12) and in vivo CNP and cGMP levels were assessed. NPRC binding with C53 and CNP were assessed using a modified AlphaScreen luminescent proximity assay (ALPA). In vitro cGMP activating property of C53 (10 −8 M and 10 −6 M) compared to no treatment in hCFs was assessed. Data are mean ± SE and significance was achieved with P < .05. Results: In vivo, C53 significantly increased plasma and urinary cGMP compared to equimolar CNP and vehicle (P < .05), which correlated with higher plasma CNP levels with C53 IV infusion (P < .05). Binding studies using the ALPA demonstrated that C53 had reduced binding to NPRC compared to CNP. In hCFs, C53 generated cGMP at 10 −8 M and markedly activated cGMP at 10 −6 M compared to no treatment (no treatment: 0.00 ± 0.00; 10 −8 M: 0.17 ± 0.03; 10 −6 M: 1.79 ± 0.02, pmol/well, P < .05). Conclusion: We report a newly engineered CNPbased peptide, C53, has cGMP activating actions in hCFs and has superior in vivo cGMP generation than CNP which may, in part, be related to reduced binding to the metabolic clearance receptor NPRC. These studies suggest that C53 may be a novel therapeutic strategy for the prevention and treatment of cardiac fibrosis in HF and further investigations are warranted.
Obstructive sleep apnea (OSA) is a form of sleep disordered breathing in which pharyngeal muscle ... more Obstructive sleep apnea (OSA) is a form of sleep disordered breathing in which pharyngeal muscle relaxation leads to recurrent nighttime apneas and hypopneas that, through increased afterload, intermittent hypoxia, and excess sympathetic activity, weaken the already failing heart. This review presents the current evidence regarding the complex relationship between OSA and heart failure (HF), including support for OSA as both a cause and consequence of HF. The impact of OSA on other cardiovascular diseases, such as hypertension, ischemic heart disease and arrhythmias, as they relate to HF development or exacerbation, also are reviewed.
Welcome to the fourth issue of Sleep Research Review. One of the studies selected for this issue ... more Welcome to the fourth issue of Sleep Research Review. One of the studies selected for this issue reports that treatment with positive airway pressure reduces 30-day readmission rates and emergency department visits in cardiac patients who are diagnosed with obstructive sleep apnoea. The study authors comment that reducing hospital admission rates for cardiac patients is essential for providing cost-effective care. Another study reports improvement in patients suffering from restless legs syndrome occurring with iron deficiency anaemia after they received treatment with intravenous iron therapy. This effect was sustained for more than 6 months in several of the patients. Best wishes for the festive season to all of our readers and I look forward to your comments and feedback throughout the coming year.
Chronic heart failure (CHF) 105 cardiovascular mortality were seen in any age or LVEF subgroup. G... more Chronic heart failure (CHF) 105 cardiovascular mortality were seen in any age or LVEF subgroup. Geographical location was not associated with any apparent impact of DMPs on the primary outcomes. Conclusion: This systematic review and subgroup meta-analysis suggests that patient age and LVEF are associated with the impact of DMPs in HF.
Heart failure is a chronic, progressive disease. Despite advances in the management of heart fail... more Heart failure is a chronic, progressive disease. Despite advances in the management of heart failure over the past 30 years, many patients will progress to an advanced stage of the disease that negatively impacts their quality of life and ultimately leads to death. As our success in managing acute coronary syndromes and sudden cardiac death has improved, more patients are surviving to end-stage heart failure. Understanding the etiology of the progression and eliminating other causes of dyspnea or edema is the first step in the management of this challenging population. For younger patients without serious comorbidities, cardiac transplantation is an alternative that may extend the quantity and improve the quality of life. For those who are not transplant candidates, there are limited options, and often the focus becomes one of maintaining function and controlling symptoms, occasionally at the expense of mortality. In truly refractory heart failure, hospice care may be appropriate in order to maintain comfort and dignity.
Journal of the American College of Cardiology, Oct 1, 2009
Over the past 15 years, the association of sleep apnea and serious medical consequences has slowl... more Over the past 15 years, the association of sleep apnea and serious medical consequences has slowly entered mainstream medicine. From a noisy and almost comical condition to one that is now recognized to be associated with serious morbidity and mortality, investigators around the world are studying the complex relationships between sleep and the neurologic, pulmonary, endocrine, and cardiovascular systems. As the evidence has mounted, screening and treatment of sleep apnea has been incorporated into clinical practice guidelines and reports for several serious medical conditions including, among others, hypertension (Joint National Committee 7) (1), heart failure (American College of Cardiology/American Heart Association [ACC/AHA]) (2), pulmonary arterial hypertension (ACC/AHA) (3), and type 2 diabetes mellitus (International Diabetes Federation) (4). This effort has culminated in an ACC/AHA scientific statement focused exclusively on sleep apnea and cardiovascular disease. This statement reviews the known mechanisms as well as the association of various forms of sleep apnea with hypertension, heart failure, stroke, arrhythmias, myocardial infarction and ischemia, pulmonary arterial hypertension, and end-stage renal disease. It concludes with a call for more study to understand mechanisms, associations, and the impact of treatment of sleep apnea on patients with and at risk for cardiovascular disease (5).
Journal of the American College of Cardiology, Mar 1, 2015
Background: Interventions designed to improve appropriate use of cardiac stress tests (CST) have ... more Background: Interventions designed to improve appropriate use of cardiac stress tests (CST) have focused primarily or exclusively on ambulatory patients. We designed a computerized order entry tool (OET) to facilitate more appropriate use of CST in hospitalized patients. methods: The OET included prompts to suggest exercise ECG testing, rather than CST with imaging, for patients who were at low risk, and links to relevant guidelines. We applied appropriate use criteria before (PRE) and after (POST) implementation of the OET. results: We studied 941 patients (478 PRE and 463 POST) over 1.5 years. Age (61 years) and gender (45% female) were similar PRE and POST. Known coronary disease was higher in the PRE group (30% vs. 23%, p=0.02). Risk factors for coronary disease were similar (average 2 risk factors per patient). About two-thirds of CST were for chest pain or ischemic equivalent and 18% were pre-operative. Of the patients with chest pain, 76% were low risk (TIMI score ≤2) and 28% were very low risk (TIMI score 0). The OET had a significant impact. Only 4% of CST were exercise ECG tests PRE, compared to 15% POST (p<0.001). The overall rate of inappropriate tests did not change significantly (12% PRE vs. 11% POST, p=0.54). However, of the patients with low risk chest pain, the rate of exercise ECG testing did increase (4% PRE vs. 17% POST, p<0.001), and inappropriate testing improved (2% PRE vs. 0% POST, p=0.05). Among very low risk patients there were similar improvements in use of exercise ECG tests (7% vs. 25%, p<0.001) and inappropriate use (3% vs. 0%, p=0.25). Most inappropriate imaging CST were pre-operative (88% vs. 11% of other tests, p<0.001). Inappropriate CST patients were more often male (66% vs. 54%, p=0.02) and white (77% vs. 44%, p<0.001), with lower rates of cardiac risk factors and less known coronary disease. conclusion: Our novel OET for CST in hospitalized patients increased the usage of exercise ECG testing, particularly among low risk chest pain patients. While the overall rate of inappropriate use did not change, it was reduced in low risk chest pain patients. Very few imaging CST were inappropriate in chest pain patients, which may reflect a limitation of the current appropriate use criteria.
Background: Interventions designed to improve appropriate use of cardiac stress tests (CST) have ... more Background: Interventions designed to improve appropriate use of cardiac stress tests (CST) have focused primarily or exclusively on ambulatory patients. We designed a computerized order entry tool (OET) to facilitate more appropriate use of CST in hospitalized patients. methods: The OET included prompts to suggest exercise ECG testing, rather than CST with imaging, for patients who were at low risk, and links to relevant guidelines. We applied appropriate use criteria before (PRE) and after (POST) implementation of the OET. results: We studied 941 patients (478 PRE and 463 POST) over 1.5 years. Age (61 years) and gender (45% female) were similar PRE and POST. Known coronary disease was higher in the PRE group (30% vs. 23%, p=0.02). Risk factors for coronary disease were similar (average 2 risk factors per patient). About two-thirds of CST were for chest pain or ischemic equivalent and 18% were pre-operative. Of the patients with chest pain, 76% were low risk (TIMI score ≤2) and 28% were very low risk (TIMI score 0). The OET had a significant impact. Only 4% of CST were exercise ECG tests PRE, compared to 15% POST (p<0.001). The overall rate of inappropriate tests did not change significantly (12% PRE vs. 11% POST, p=0.54). However, of the patients with low risk chest pain, the rate of exercise ECG testing did increase (4% PRE vs. 17% POST, p<0.001), and inappropriate testing improved (2% PRE vs. 0% POST, p=0.05). Among very low risk patients there were similar improvements in use of exercise ECG tests (7% vs. 25%, p<0.001) and inappropriate use (3% vs. 0%, p=0.25). Most inappropriate imaging CST were pre-operative (88% vs. 11% of other tests, p<0.001). Inappropriate CST patients were more often male (66% vs. 54%, p=0.02) and white (77% vs. 44%, p<0.001), with lower rates of cardiac risk factors and less known coronary disease. conclusion: Our novel OET for CST in hospitalized patients increased the usage of exercise ECG testing, particularly among low risk chest pain patients. While the overall rate of inappropriate use did not change, it was reduced in low risk chest pain patients. Very few imaging CST were inappropriate in chest pain patients, which may reflect a limitation of the current appropriate use criteria.
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