This research article examines whether African Americans with chronic systolic heart failure respond differently to cardiac resynchronization therapy-defibrillator (CRT-D) compared to non-African Americans. The study analyzed data from 212 patients who received CRT-D implants between 2009-2013. Baseline characteristics were similar between the 130 African American patients and 82 non-African American patients. The primary outcome of left ventricular ejection fraction improvement of at least 5% was seen in 62.3% of African Americans and 59.8% of non-African Americans, showing similar response rates. Secondary clinical outcomes like hospitalizations and mortality were also comparable between the groups. Among responders, factors like age, comorbidities, and ech
Cardiac Allograft Vasculopathy in Redo-Transplants- Is It More or Less (or) t...Anya Ragnhildstveit
This study examined the relationship between the MELD-XI score and mortality in patients who received an orthotopic heart transplant (OHT). The researchers analyzed data from over 27,000 OHT patients between 2002-2012 from the United Network for Organ Sharing database. They found that 22% of patients had a MELD-XI score over 17 at the time of transplant. Higher MELD-XI scores were associated with significantly lower 30-day, 1-year, and 5-year survival rates compared to those with lower scores. After adjusting for other factors, a high MELD-XI score remained an independent predictor of increased mortality at 30 days, 1 year, and 5 years following OHT. This large study demonstrates
Elevated Tissue Doppler E/E' on Index Admission Can Help Identify Patients at...crimsonpublishersOJCHD
Readmissions for congestive Heart Failure (CHF) are a major healthcare problem that contributes significantly to the overall healthcare expenditure. About 24% of patients are readmitted to the hospital within 30 days of discharge. We investigated whether a non-invasive estimate of left atrial filling pressure, an elevated ratio of early trans mitral flow velocity to early diastolic mitral annular velocity (E/E'), during the index admission for CHF could independently predict 30 day readmission.
This document summarizes a study examining medical and neurological complications in 279 patients with acute ischemic stroke. The study found that 95% of patients experienced at least one complication. The most common serious medical complication was pneumonia (5%) and the most common serious neurological complication was new or extended cerebral infarction (5%). Medical complications contributed to 51% of deaths within 3 months. Patients with serious medical complications had significantly worse outcomes on functional scales even after accounting for baseline differences.
Guidelines For Assessment Of C Visk In Rsymptomatic AdultsJuan Menendez
The document provides guidelines for cardiovascular risk assessment in asymptomatic adults from the 2010 ACCF/AHA. It recommends using global risk scores that incorporate multiple traditional risk factors. It recommends obtaining family history of CVD but does not recommend genetic testing. It also does not recommend various tests such as natriuretic peptides, lipid assessments beyond standard profiles, or C-reactive protein in certain groups. It provides recommendations for use of other tests in specific intermediate-risk groups such as carotid intima-media thickness or coronary artery calcium scoring.
Cardiac risk evaluation: searching for the vulnerable patient FELIX NUNURA
The document discusses screening patients for cardiovascular risk factors and disease. It outlines various risk assessment tools like the Framingham Risk Score and SCORE that estimate risk based on factors like age, cholesterol levels, blood pressure, smoking status. It discusses limitations of risk factor-based screening and emphasizes the importance of directly measuring subclinical disease using tests like coronary artery calcium scoring and carotid intima-media thickness to identify vulnerable patients. The document advocates screening for and treating the underlying atherosclerotic disease rather than just risk factors to improve prevention outcomes.
The goal of this webinar is to educate physicians and healthcare professionals about hospice eligibility and benefits for patients with advanced cardiac disease (ACD) who have a prognosis of ≤6 months. Through evidence-based data and a review of case studies, attendees understand the benefits of advance care planning, complex modalities for high-acuity cardiac patients, how to manage symptoms, address pain and provide comfort and dignity near the end of life.
Introduction: Chronic Kidney Disease (CKD) is a worldwide public health problem and it is increasing over time. Cardiovascular disease is a major concern for patients with end stage renal disease, especially those on hemodialysis. It is the leading cause of death among patients with chronic kidney
disease, particularly in dialysis population.
Cardiac Allograft Vasculopathy in Redo-Transplants- Is It More or Less (or) t...Anya Ragnhildstveit
This study examined the relationship between the MELD-XI score and mortality in patients who received an orthotopic heart transplant (OHT). The researchers analyzed data from over 27,000 OHT patients between 2002-2012 from the United Network for Organ Sharing database. They found that 22% of patients had a MELD-XI score over 17 at the time of transplant. Higher MELD-XI scores were associated with significantly lower 30-day, 1-year, and 5-year survival rates compared to those with lower scores. After adjusting for other factors, a high MELD-XI score remained an independent predictor of increased mortality at 30 days, 1 year, and 5 years following OHT. This large study demonstrates
Elevated Tissue Doppler E/E' on Index Admission Can Help Identify Patients at...crimsonpublishersOJCHD
Readmissions for congestive Heart Failure (CHF) are a major healthcare problem that contributes significantly to the overall healthcare expenditure. About 24% of patients are readmitted to the hospital within 30 days of discharge. We investigated whether a non-invasive estimate of left atrial filling pressure, an elevated ratio of early trans mitral flow velocity to early diastolic mitral annular velocity (E/E'), during the index admission for CHF could independently predict 30 day readmission.
This document summarizes a study examining medical and neurological complications in 279 patients with acute ischemic stroke. The study found that 95% of patients experienced at least one complication. The most common serious medical complication was pneumonia (5%) and the most common serious neurological complication was new or extended cerebral infarction (5%). Medical complications contributed to 51% of deaths within 3 months. Patients with serious medical complications had significantly worse outcomes on functional scales even after accounting for baseline differences.
Guidelines For Assessment Of C Visk In Rsymptomatic AdultsJuan Menendez
The document provides guidelines for cardiovascular risk assessment in asymptomatic adults from the 2010 ACCF/AHA. It recommends using global risk scores that incorporate multiple traditional risk factors. It recommends obtaining family history of CVD but does not recommend genetic testing. It also does not recommend various tests such as natriuretic peptides, lipid assessments beyond standard profiles, or C-reactive protein in certain groups. It provides recommendations for use of other tests in specific intermediate-risk groups such as carotid intima-media thickness or coronary artery calcium scoring.
Cardiac risk evaluation: searching for the vulnerable patient FELIX NUNURA
The document discusses screening patients for cardiovascular risk factors and disease. It outlines various risk assessment tools like the Framingham Risk Score and SCORE that estimate risk based on factors like age, cholesterol levels, blood pressure, smoking status. It discusses limitations of risk factor-based screening and emphasizes the importance of directly measuring subclinical disease using tests like coronary artery calcium scoring and carotid intima-media thickness to identify vulnerable patients. The document advocates screening for and treating the underlying atherosclerotic disease rather than just risk factors to improve prevention outcomes.
The goal of this webinar is to educate physicians and healthcare professionals about hospice eligibility and benefits for patients with advanced cardiac disease (ACD) who have a prognosis of ≤6 months. Through evidence-based data and a review of case studies, attendees understand the benefits of advance care planning, complex modalities for high-acuity cardiac patients, how to manage symptoms, address pain and provide comfort and dignity near the end of life.
Introduction: Chronic Kidney Disease (CKD) is a worldwide public health problem and it is increasing over time. Cardiovascular disease is a major concern for patients with end stage renal disease, especially those on hemodialysis. It is the leading cause of death among patients with chronic kidney
disease, particularly in dialysis population.
This document summarizes two studies that raised questions about the risks and benefits of testosterone therapy:
1. A retrospective study found that male veterans with low testosterone who received testosterone therapy had a higher risk of heart attack, stroke, or death compared to those not receiving therapy, even after adjusting for potential confounding factors.
2. A randomized trial found that adding testosterone to optimized sildenafil therapy for erectile dysfunction provided no additional improvement in erectile function compared to sildenafil alone.
Together these studies highlight the need for more research on the long-term risks and benefits of testosterone therapy, as current understanding is limited despite its increasing use.
Heart failure is the leading cause of death in the US, yet accounts for less than 20 percent of hospice admissions. The goal of this webinar is to teach healthcare professionals to recognize what were once routine and manageable exacerbations as signs of unstable terminal illness, and to understand why hospice improves quality of life when proven treatments no longer can can.
The document summarizes the recommendations of the 2014 JNC 8 guidelines for treatment of hypertension. It discusses:
1) The JNC 8 recommendation to initiate pharmacologic treatment for those aged 60 and older with a systolic blood pressure of 150 mm Hg or higher, and to treat to a goal of under 150 mm Hg.
2) Evidence from trials supporting this recommendation showing reduced risks of stroke, heart failure, and coronary heart disease with treatment to a goal of under 150 mm Hg.
3) Arguments against recommending treatment to lower goals not proven in clinical trials, such as unnecessary exposure to medication side effects and polypharmacy in the elderly.
The document discusses advances and ongoing disparities in heart failure treatment for African Americans. It summarizes the key findings of the landmark AHEFT trial from 2004, which found that the combination of isosorbide dinitrate and hydralazine reduced mortality and hospitalization rates in African Americans with heart failure compared to placebo. However, the document notes that a decade later, many African American heart failure patients are still not receiving guideline-directed medical therapies. It argues that future clinical trials of novel heart failure drugs need to incorporate background therapies across all demographic groups to truly advance health equity in heart failure care for African Americans through a paradigm shift, rather than just a paradigm drift.
JNC 8 guidelines are criticized for not being truly evidence-based. Most recommendations received a grade of evidence of D or E. The guidelines raise red flags for potential biases due to financial conflicts of interest among panel members. Recommending higher blood pressure targets may increase stroke risk for vulnerable groups. The guidelines are accused of not considering all available evidence and prioritizing improved statistics over patient outcomes.
The panel recommends the following for treatment of hypertension in adults:
- For ages 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For ages 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those under 30, or ages 60 or older with diabetes or kidney disease, treat to a goal of less than 140/90 mm Hg.
- Initial drug treatment should include a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker.
- For nonblack populations, including those with diabetes, consider a
Eighth Joint National Committee (JNC 8) - Blood Pressure in AdultsSandru Acevedo MD
The panel recommends the following for treatment of hypertension in adults:
- For patients aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For patients aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For nonblack patients, including those with diabetes, initially treat with a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker.
- For black patients, including those with diabetes, initially treat with a calcium channel blocker or thiazide-type diuretic.
Based on the information provided:
D) Introduce a non-monitored oral anticoagulant to the patient's regimen.
Given her history of intolerance to warfarin and documented GI bleed on aspirin and clopidogrel, a non-monitored oral anticoagulant like dabigatran, rivaroxaban or apixaban would be a reasonable option to reduce her stroke risk while avoiding the need for frequent INR monitoring or dual antiplatelet therapy that may increase her bleeding risk.
Prognosis of pulmonary arterial hypertensiongisa_legal
1) The expected survival of patients with pulmonary arterial hypertension (PAH) varies based on the underlying cause, with idiopathic PAH having a median survival of 2.8 years based on historical studies.
2) Medical therapies like epoprostenol have improved survival rates, with studies showing 1, 2, and 3 year survival rates with epoprostenol between 63-87%, compared to 27-52% historically.
3) The prognosis is worse for PAH associated with scleroderma or collagen vascular diseases, with median survival around 1-2 years, while PAH associated with congenital heart disease has a better prognosis, with reported 3 year survival of 77%.
This study compared the long-term (18-month) outcomes of supervised exercise (SE), stent revascularization (ST), and optimal medical therapy (OMT) for patients with claudication due to aortoiliac peripheral artery disease. 79 patients completed the 18-month follow-up assessment. The study found that both SE and ST resulted in significantly greater improvements in peak walking time and claudication onset time compared to OMT. SE and ST also provided durable improvements in quality of life measures up to 18 months. Both SE and ST had better long-term outcomes than OMT alone for treating claudication, demonstrating the durability of exercise interventions for peripheral artery disease.
This document discusses strategies for screening patients for cardiovascular risk. It highlights several methods for evaluating risk, including calculating risk scores based on traditional risk factors as well as screening for subclinical disease using tests such as coronary artery calcium scoring and carotid intima-media thickness measurements. Finding and treating disease early, before symptoms occur, is important as atherosclerosis often begins decades before clinical events. Screening for and treating the underlying disease, not just risk factors, may help identify vulnerable patients at highest risk.
This document provides a summary of the November 2014 issue of the UTSW Internal Medicine Journal Watch. It includes summaries of articles on topics such as assessing acid-base disturbances, managing Staphylococcus aureus bacteremia, community acquired pneumonia, predicting hepatocellular carcinoma in hepatitis C patients, and guidelines for prioritizing patients for new hepatitis C treatments. It also reviews articles related to infectious diseases, critical care, nephrology, cardiology, and more.
The document summarizes the key findings and recommendations from a systematic review of evidence on the management of high blood pressure conducted by the Eighth Joint National Committee panel members. The panel recommends treating hypertensive patients aged 60 or older to a blood pressure goal of less than 150/90 mm Hg, and those aged 30-59 to a goal of less than 140/90 mm Hg. For nonblack patients, including those with diabetes, initial drug treatment should include a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker. For black patients, including those with diabetes, a calcium channel blocker or thiazide-type di
Prevention of recurrent stroke in atrial fibrillation Jacek StaszewskiJacek Staszewski
Prevention of recurrent stroke in atrial fibrillation. Comaprison of NOAC vs VKA. Riks of hemorrhagic stroke. When anticoagulation should be initiated following acute stroke.
This document summarizes the recommendations from an expert panel on the management of high blood pressure in adults. Key recommendations include:
1) Treating all adults aged 60 or older to a blood pressure under 150/90 mm Hg and those aged 30-59 to under 140/90 mm Hg.
2) Initial drug treatment for most nonblack adults should include a thiazide diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker. For black adults, initial treatment is a calcium channel blocker or thiazide diuretic.
3) Treatment goals are the same for adults with diabetes or nondiabetic kidney disease as the
Inter society consensus for the management of peripheral arterial disease (tasc)Jonathan Campos
This document summarizes the key findings of the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). It discusses the prevalence of peripheral arterial disease (PAD), finding that PAD affects approximately 3-10% of the general population but is asymptomatic in around 75% of cases. The ratio of asymptomatic to symptomatic PAD is estimated to be between 3:1 and 4:1. Symptomatic PAD presents mainly as intermittent claudication. The document also outlines the grading system used to rate the strength of recommendations.
A 65-year-old female presented with palpitations and was found to be in atrial fibrillation. The document discusses:
1) Rate control vs rhythm control strategies for managing atrial fibrillation.
2) Anticoagulation is recommended based on stroke risk scores like CHA2DS2-VASc.
3) For this patient, with a history of dyslipidemia and no other risk factors, oral anticoagulation is recommended based on her moderate stroke risk.
The new guidelines for treatment of primary hypertension. JNC 8. Samir Rafla-JNC 8-2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults.
Mangement of chronic heart failure 93432-rephrasedIrfan iftekhar
Cardiac resynchronization therapy significantly reduces morbidity and mortality in patients with heart failure. A randomized controlled trial found that cardiac resynchronization reduced the primary endpoint of death from any cause by 36% compared to medical therapy alone. Mortality was lower in the cardiac resynchronization group, demonstrating improved outcomes. While cardiac resynchronization is an effective treatment, its cost-effectiveness remains uncertain due to the therapy's expense. Further research is still needed to determine its overall value.
This document summarizes two studies that raised questions about the risks and benefits of testosterone therapy:
1. A retrospective study found that male veterans with low testosterone who received testosterone therapy had a higher risk of heart attack, stroke, or death compared to those not receiving therapy, even after adjusting for potential confounding factors.
2. A randomized trial found that adding testosterone to optimized sildenafil therapy for erectile dysfunction provided no additional improvement in erectile function compared to sildenafil alone.
Together these studies highlight the need for more research on the long-term risks and benefits of testosterone therapy, as current understanding is limited despite its increasing use.
Heart failure is the leading cause of death in the US, yet accounts for less than 20 percent of hospice admissions. The goal of this webinar is to teach healthcare professionals to recognize what were once routine and manageable exacerbations as signs of unstable terminal illness, and to understand why hospice improves quality of life when proven treatments no longer can can.
The document summarizes the recommendations of the 2014 JNC 8 guidelines for treatment of hypertension. It discusses:
1) The JNC 8 recommendation to initiate pharmacologic treatment for those aged 60 and older with a systolic blood pressure of 150 mm Hg or higher, and to treat to a goal of under 150 mm Hg.
2) Evidence from trials supporting this recommendation showing reduced risks of stroke, heart failure, and coronary heart disease with treatment to a goal of under 150 mm Hg.
3) Arguments against recommending treatment to lower goals not proven in clinical trials, such as unnecessary exposure to medication side effects and polypharmacy in the elderly.
The document discusses advances and ongoing disparities in heart failure treatment for African Americans. It summarizes the key findings of the landmark AHEFT trial from 2004, which found that the combination of isosorbide dinitrate and hydralazine reduced mortality and hospitalization rates in African Americans with heart failure compared to placebo. However, the document notes that a decade later, many African American heart failure patients are still not receiving guideline-directed medical therapies. It argues that future clinical trials of novel heart failure drugs need to incorporate background therapies across all demographic groups to truly advance health equity in heart failure care for African Americans through a paradigm shift, rather than just a paradigm drift.
JNC 8 guidelines are criticized for not being truly evidence-based. Most recommendations received a grade of evidence of D or E. The guidelines raise red flags for potential biases due to financial conflicts of interest among panel members. Recommending higher blood pressure targets may increase stroke risk for vulnerable groups. The guidelines are accused of not considering all available evidence and prioritizing improved statistics over patient outcomes.
The panel recommends the following for treatment of hypertension in adults:
- For ages 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For ages 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those under 30, or ages 60 or older with diabetes or kidney disease, treat to a goal of less than 140/90 mm Hg.
- Initial drug treatment should include a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker.
- For nonblack populations, including those with diabetes, consider a
Eighth Joint National Committee (JNC 8) - Blood Pressure in AdultsSandru Acevedo MD
The panel recommends the following for treatment of hypertension in adults:
- For patients aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For patients aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For nonblack patients, including those with diabetes, initially treat with a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker.
- For black patients, including those with diabetes, initially treat with a calcium channel blocker or thiazide-type diuretic.
Based on the information provided:
D) Introduce a non-monitored oral anticoagulant to the patient's regimen.
Given her history of intolerance to warfarin and documented GI bleed on aspirin and clopidogrel, a non-monitored oral anticoagulant like dabigatran, rivaroxaban or apixaban would be a reasonable option to reduce her stroke risk while avoiding the need for frequent INR monitoring or dual antiplatelet therapy that may increase her bleeding risk.
Prognosis of pulmonary arterial hypertensiongisa_legal
1) The expected survival of patients with pulmonary arterial hypertension (PAH) varies based on the underlying cause, with idiopathic PAH having a median survival of 2.8 years based on historical studies.
2) Medical therapies like epoprostenol have improved survival rates, with studies showing 1, 2, and 3 year survival rates with epoprostenol between 63-87%, compared to 27-52% historically.
3) The prognosis is worse for PAH associated with scleroderma or collagen vascular diseases, with median survival around 1-2 years, while PAH associated with congenital heart disease has a better prognosis, with reported 3 year survival of 77%.
This study compared the long-term (18-month) outcomes of supervised exercise (SE), stent revascularization (ST), and optimal medical therapy (OMT) for patients with claudication due to aortoiliac peripheral artery disease. 79 patients completed the 18-month follow-up assessment. The study found that both SE and ST resulted in significantly greater improvements in peak walking time and claudication onset time compared to OMT. SE and ST also provided durable improvements in quality of life measures up to 18 months. Both SE and ST had better long-term outcomes than OMT alone for treating claudication, demonstrating the durability of exercise interventions for peripheral artery disease.
This document discusses strategies for screening patients for cardiovascular risk. It highlights several methods for evaluating risk, including calculating risk scores based on traditional risk factors as well as screening for subclinical disease using tests such as coronary artery calcium scoring and carotid intima-media thickness measurements. Finding and treating disease early, before symptoms occur, is important as atherosclerosis often begins decades before clinical events. Screening for and treating the underlying disease, not just risk factors, may help identify vulnerable patients at highest risk.
This document provides a summary of the November 2014 issue of the UTSW Internal Medicine Journal Watch. It includes summaries of articles on topics such as assessing acid-base disturbances, managing Staphylococcus aureus bacteremia, community acquired pneumonia, predicting hepatocellular carcinoma in hepatitis C patients, and guidelines for prioritizing patients for new hepatitis C treatments. It also reviews articles related to infectious diseases, critical care, nephrology, cardiology, and more.
The document summarizes the key findings and recommendations from a systematic review of evidence on the management of high blood pressure conducted by the Eighth Joint National Committee panel members. The panel recommends treating hypertensive patients aged 60 or older to a blood pressure goal of less than 150/90 mm Hg, and those aged 30-59 to a goal of less than 140/90 mm Hg. For nonblack patients, including those with diabetes, initial drug treatment should include a thiazide-type diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker. For black patients, including those with diabetes, a calcium channel blocker or thiazide-type di
Prevention of recurrent stroke in atrial fibrillation Jacek StaszewskiJacek Staszewski
Prevention of recurrent stroke in atrial fibrillation. Comaprison of NOAC vs VKA. Riks of hemorrhagic stroke. When anticoagulation should be initiated following acute stroke.
This document summarizes the recommendations from an expert panel on the management of high blood pressure in adults. Key recommendations include:
1) Treating all adults aged 60 or older to a blood pressure under 150/90 mm Hg and those aged 30-59 to under 140/90 mm Hg.
2) Initial drug treatment for most nonblack adults should include a thiazide diuretic, calcium channel blocker, angiotensin-converting enzyme inhibitor, or angiotensin receptor blocker. For black adults, initial treatment is a calcium channel blocker or thiazide diuretic.
3) Treatment goals are the same for adults with diabetes or nondiabetic kidney disease as the
Inter society consensus for the management of peripheral arterial disease (tasc)Jonathan Campos
This document summarizes the key findings of the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). It discusses the prevalence of peripheral arterial disease (PAD), finding that PAD affects approximately 3-10% of the general population but is asymptomatic in around 75% of cases. The ratio of asymptomatic to symptomatic PAD is estimated to be between 3:1 and 4:1. Symptomatic PAD presents mainly as intermittent claudication. The document also outlines the grading system used to rate the strength of recommendations.
A 65-year-old female presented with palpitations and was found to be in atrial fibrillation. The document discusses:
1) Rate control vs rhythm control strategies for managing atrial fibrillation.
2) Anticoagulation is recommended based on stroke risk scores like CHA2DS2-VASc.
3) For this patient, with a history of dyslipidemia and no other risk factors, oral anticoagulation is recommended based on her moderate stroke risk.
The new guidelines for treatment of primary hypertension. JNC 8. Samir Rafla-JNC 8-2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults.
Mangement of chronic heart failure 93432-rephrasedIrfan iftekhar
Cardiac resynchronization therapy significantly reduces morbidity and mortality in patients with heart failure. A randomized controlled trial found that cardiac resynchronization reduced the primary endpoint of death from any cause by 36% compared to medical therapy alone. Mortality was lower in the cardiac resynchronization group, demonstrating improved outcomes. While cardiac resynchronization is an effective treatment, its cost-effectiveness remains uncertain due to the therapy's expense. Further research is still needed to determine its overall value.
1) Patients with advanced heart failure who were on optimal medical therapy faced poor survival and quality of life and high risk of death.
2) The study prospectively observed 166 ambulatory patients with advanced heart failure who were at high risk of death based on clinical features and hospitalization history.
3) At 1 year, only 47% of patients remained alive without mechanical circulatory support (MCS) or transplant, and risk of death or need for MCS varied significantly based on the patient's baseline INTERMACS profile.
We conducted a retrospective study of 178 community dwelling elderly on anemia which was defined as hemoglobin < 13 gm/ dl in males and < 12 gm/dl in females (WHO guidelines).
Methods: This was a retrospective chart review of patients aged ≥ 95 years, who were seen over a two year period at the University of Arkansas for Medical Sciences.
The panel recommends the following for treatment of hypertension in adults:
- For those aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For those aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those younger than 60 years with diabetes or chronic kidney disease, treat to a blood pressure goal of less than 140/90 mm Hg.
- Initiate treatment with one of four classes of antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic).
- For non
Jnc 8 guidelines for management of high blood pressure: Lets compare with JNC 7Dr. Afzal Haq Asif
This guideline from the Eighth Joint National Committee provides evidence-based recommendations for the management of high blood pressure in adults. There is strong evidence that treating hypertensive patients aged 60 years or older to a blood pressure goal of less than 150/90 mm Hg and those aged 30-59 years to a goal of less than 90 mm Hg improves health outcomes. For hypertensive patients under age 60, a goal of less than 140/90 mm Hg is recommended based on expert opinion due to insufficient evidence for specific systolic and diastolic goals. The guideline also recommends initiating drug treatment for hypertension with certain classes of medications, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium
The panel recommends the following for treatment of hypertension in adults:
- For those aged 60 years and older, treat to a blood pressure goal of less than 150/90 mm Hg.
- For those aged 30-59 years, treat to a blood pressure goal of less than 140/90 mm Hg.
- For those younger than 60 years with diabetes or chronic kidney disease, treat to a blood pressure goal of less than 140/90 mm Hg.
- Initiate treatment with one of four classes of antihypertensive drugs (angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic). The most appropriate first
The panel recommends the following based on its systematic review of evidence:
1) For most adults aged 60 years or older, treat SBP to a goal of less than 150 mm Hg and DBP to a goal of less than 90 mm Hg.
2) For nonblack adults younger than 60 years, treat SBP to a goal of less than 140 mm Hg and DBP to a goal of less than 90 mm Hg.
3) Initial drug treatment should include thiazide-type diuretics, calcium channel blockers, ACE inhibitors, or ARBs.
Among patients with heart failure with preserved ejection fraction (HFPEF), a randomized clinical trial found that 24 weeks of treatment with the phosphodiesterase-5 inhibitor sildenafil, compared to placebo, did not significantly improve exercise capacity as measured by peak oxygen consumption or clinical status. Median changes in peak oxygen consumption and 6-minute walk distance were not significantly different between the sildenafil and placebo groups. The mean clinical status rank score, a composite of time to death or hospitalization and quality of life, was also not significantly different between groups at 24 weeks. Adverse events occurred in similar proportions of patients in both groups.
Copyright 2016 American Medical Association. All rights reserv.docxmelvinjrobinson2199
Copyright 2016 American Medical Association. All rights reserved.
Intensive vs Standard Blood Pressure Control
and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years
A Randomized Clinical Trial
Jeff D. Williamson, MD, MHS; Mark A. Supiano, MD; William B. Applegate, MD, MPH; Dan R. Berlowitz, MD; Ruth C. Campbell, MD, MSPH;
Glenn M. Chertow, MD; Larry J. Fine, MD; William E. Haley, MD; Amret T. Hawfield, MD; Joachim H. Ix, MD, MAS; Dalane W. Kitzman, MD;
John B. Kostis, MD; Marie A. Krousel-Wood, MD; Lenore J. Launer, PhD; Suzanne Oparil, MD; Carlos J. Rodriguez, MD, MPH;
Christianne L. Roumie, MD, MPH; Ronald I. Shorr, MD, MS; Kaycee M. Sink, MD, MAS; Virginia G. Wadley, PhD; Paul K. Whelton, MD;
Jeffrey Whittle, MD; Nancy F. Woolard; Jackson T. Wright Jr, MD, PhD; Nicholas M. Pajewski, PhD; for the SPRINT Research Group
IMPORTANCE The appropriate treatment target for systolic blood pressure (SBP) in older
patients with hypertension remains uncertain.
OBJECTIVE To evaluate the effects of intensive (<120 mm Hg) compared with standard
(<140 mm Hg) SBP targets in persons aged 75 years or older with hypertension
but without diabetes.
DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial of patients aged
75 years or older who participated in the Systolic Blood Pressure Intervention Trial (SPRINT).
Recruitment began on October 20, 2010, and follow-up ended on August 20, 2015.
INTERVENTIONS Participants were randomized to an SBP target of less than 120 mm Hg
(intensive treatment group, n = 1317) or an SBP target of less than 140 mm Hg (standard
treatment group, n = 1319).
MAIN OUTCOMES AND MEASURES The primary cardiovascular disease outcome was a
composite of nonfatal myocardial infarction, acute coronary syndrome not resulting in a
myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death
from cardiovascular causes. All-cause mortality was a secondary outcome.
RESULTS Among 2636 participants (mean age, 79.9 years; 37.9% women), 2510 (95.2%)
provided complete follow-up data. At a median follow-up of 3.14 years, there was a
significantly lower rate of the primary composite outcome (102 events in the intensive
treatment group vs 148 events in the standard treatment group; hazard ratio [HR], 0.66
[95% CI, 0.51-0.85]) and all-cause mortality (73 deaths vs 107 deaths, respectively; HR, 0.67
[95% CI, 0.49-0.91]). The overall rate of serious adverse events was not different between
treatment groups (48.4% in the intensive treatment group vs 48.3% in the standard
treatment group; HR, 0.99 [95% CI, 0.89-1.11]). Absolute rates of hypotension were 2.4% in
the intensive treatment group vs 1.4% in the standard treatment group (HR, 1.71 [95% CI,
0.97-3.09]), 3.0% vs 2.4%, respectively, for syncope (HR, 1.23 [95% CI, 0.76-2.00]), 4.0% vs
2.7% for electrolyte abnormalities (HR, 1.51 [95% CI, 0.99-2.33]), 5.5% vs 4.0% for acute
kidney injury (HR, 1.41 [95% CI, 0.98-2.04]), and 4.9% vs 5.5% for inj.
Copyright 2016 American Medical Association. All rights reserv.docxbobbywlane695641
Copyright 2016 American Medical Association. All rights reserved.
Intensive vs Standard Blood Pressure Control
and Cardiovascular Disease Outcomes in Adults Aged ≥75 Years
A Randomized Clinical Trial
Jeff D. Williamson, MD, MHS; Mark A. Supiano, MD; William B. Applegate, MD, MPH; Dan R. Berlowitz, MD; Ruth C. Campbell, MD, MSPH;
Glenn M. Chertow, MD; Larry J. Fine, MD; William E. Haley, MD; Amret T. Hawfield, MD; Joachim H. Ix, MD, MAS; Dalane W. Kitzman, MD;
John B. Kostis, MD; Marie A. Krousel-Wood, MD; Lenore J. Launer, PhD; Suzanne Oparil, MD; Carlos J. Rodriguez, MD, MPH;
Christianne L. Roumie, MD, MPH; Ronald I. Shorr, MD, MS; Kaycee M. Sink, MD, MAS; Virginia G. Wadley, PhD; Paul K. Whelton, MD;
Jeffrey Whittle, MD; Nancy F. Woolard; Jackson T. Wright Jr, MD, PhD; Nicholas M. Pajewski, PhD; for the SPRINT Research Group
IMPORTANCE The appropriate treatment target for systolic blood pressure (SBP) in older
patients with hypertension remains uncertain.
OBJECTIVE To evaluate the effects of intensive (<120 mm Hg) compared with standard
(<140 mm Hg) SBP targets in persons aged 75 years or older with hypertension
but without diabetes.
DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial of patients aged
75 years or older who participated in the Systolic Blood Pressure Intervention Trial (SPRINT).
Recruitment began on October 20, 2010, and follow-up ended on August 20, 2015.
INTERVENTIONS Participants were randomized to an SBP target of less than 120 mm Hg
(intensive treatment group, n = 1317) or an SBP target of less than 140 mm Hg (standard
treatment group, n = 1319).
MAIN OUTCOMES AND MEASURES The primary cardiovascular disease outcome was a
composite of nonfatal myocardial infarction, acute coronary syndrome not resulting in a
myocardial infarction, nonfatal stroke, nonfatal acute decompensated heart failure, and death
from cardiovascular causes. All-cause mortality was a secondary outcome.
RESULTS Among 2636 participants (mean age, 79.9 years; 37.9% women), 2510 (95.2%)
provided complete follow-up data. At a median follow-up of 3.14 years, there was a
significantly lower rate of the primary composite outcome (102 events in the intensive
treatment group vs 148 events in the standard treatment group; hazard ratio [HR], 0.66
[95% CI, 0.51-0.85]) and all-cause mortality (73 deaths vs 107 deaths, respectively; HR, 0.67
[95% CI, 0.49-0.91]). The overall rate of serious adverse events was not different between
treatment groups (48.4% in the intensive treatment group vs 48.3% in the standard
treatment group; HR, 0.99 [95% CI, 0.89-1.11]). Absolute rates of hypotension were 2.4% in
the intensive treatment group vs 1.4% in the standard treatment group (HR, 1.71 [95% CI,
0.97-3.09]), 3.0% vs 2.4%, respectively, for syncope (HR, 1.23 [95% CI, 0.76-2.00]), 4.0% vs
2.7% for electrolyte abnormalities (HR, 1.51 [95% CI, 0.99-2.33]), 5.5% vs 4.0% for acute
kidney injury (HR, 1.41 [95% CI, 0.98-2.04]), and 4.9% vs 5.5% for inj.
This document summarizes guidelines from the Eighth Joint National Committee for the management of high blood pressure in adults. It recommends treating hypertensive patients aged 60 or older to a blood pressure goal of less than 150/90 mm Hg, and those aged 30-59 to a diastolic goal of less than 90 mm Hg. For those under 60, the recommended goal is less than 140/90 mm Hg based on expert opinion due to insufficient evidence. The same thresholds and goals are recommended for hypertensive adults with diabetes or chronic kidney disease under age 60. The guidelines recommend initial drug treatment for nonblack patients with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers,
Circulation 2015-criterios de jones reviewgisa_legal
This document revises the Jones criteria for diagnosing acute rheumatic fever to better align with current evidence and international guidelines. It recognizes that acute rheumatic fever remains a serious health problem globally. The revisions define high-risk populations, acknowledge variability in clinical presentation among these groups, and include Doppler echocardiography as a tool for diagnosing cardiac involvement even without overt symptoms. This represents the first major revision to the Jones criteria by the American Heart Association in over 20 years and applies their classification system for recommendations and evidence levels.
Circulation 2015-criterios de jones reviewgisa_legal
This document revises the Jones criteria for diagnosing acute rheumatic fever to better align with current evidence and international guidelines. It recognizes that acute rheumatic fever remains a serious health problem globally. The revisions define high-risk populations, acknowledge variability in clinical presentation among these groups, and include Doppler echocardiography as a tool for diagnosing cardiac involvement even without overt symptoms. This represents the first major revision to the Jones criteria by the American Heart Association in over 20 years and applies their classification system for recommendations and evidence levels.
This study surveyed 46 hemodialysis patients about arrhythmia symptoms and willingness to use an implantable cardiac monitor. The key findings were:
1) Arrhythmia symptoms were common, with 74% reporting at least one symptom such as heart palpitations or feeling like passing out.
2) Acceptability of the implantable cardiac monitor was high, with 59% of symptomatic patients and 50% of asymptomatic patients willing to consider it.
3) The main reason patients gave for not wanting the monitor was simply not wanting an implanted device, not concerns about the procedure or complications.
The document is a summary of evidence-based guidelines for managing high blood pressure in adults. It recommends:
1) Treating hypertensive persons aged 60 or older to a blood pressure goal of less than 150/90 mm Hg, and those aged 30-59 to less than 140/90 mm Hg.
2) Initiating drug treatment for nonblack populations with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, or thiazide-type diuretics. For black populations, recommend calcium channel blockers or thiazide-type diuretics.
3) Treating hypertensive adults with diabetes or chronic kidney disease to
Interheart risk modifiable factors in micardio infraction 2004Medicina
This document summarizes the objectives and methods of the INTERHEART study, a large international case-control study designed to assess the importance of cardiovascular risk factors worldwide. The study aimed to enroll approximately 15,000 cases of acute myocardial infarction and a similar number of controls from 52 countries representing all inhabited continents. The study investigated the association between nine modifiable risk factors (smoking, lipids, hypertension, diabetes, obesity, diet, physical activity, alcohol consumption, psychosocial factors) and the risk of myocardial infarction. Standardized questionnaires and physical examinations were used to collect information from all participants. Blood samples were also collected to analyze lipid levels. The results of this large, global study could help determine if cardiovascular risk factors have similar or
Predicting Trends in Preventive Care Service Utilization Impacting Cardiovasc...gpartha85
National reports point towards disparities in the utilization of preventive care services but sparse literature exists regarding predicting utilization pattern of preventive care services.
METHODS: The 2007 Medical Expenditure Panel Survey (MEPS), a national probability sample survey of the ambulatory civilian US population, was analyzed to determine demographic patterns of utilization. Recommendations by JNC-VII and NCEP were used to determine guideline adherence to blood pressure and cholesterol checkup respectively. Utilization of blood pressure screening and cholesterol checkup services were used as the dependent variable while age, gender, race, ethnicity, insurance status, perceived health status were used as independent variables. Since guidelines differ for people with elevated blood pressure, respondents with elevated blood pressure were identified in the MEPS database by self-reported diagnosis. Descriptive statistics were used to describe the population, chi-square analysis was used to determine the group differences for the categorical variables. Multivariate logistic regression model was built to predict odds of utilizing appropriate preventive se!
rvices. All analysis was carried out using SAS v9.1.
RESULTS: Total number of adult respondents was 20,434 of which data was available for blood pressure checkup for 20,187 respondents and 15,784 respondents for cholesterol checkup. Overall, respondents were found to adhere to guideline recommendations for getting the blood pressure (n=17,959, 89.0%) and cholesterol (n=14,956, 94.7%) check-up done. A univariate chi-square analysis showed statistically significant differences across all independent variables between people who utilized the preventive care service and those who didn t for blood pressure checkup (p<0><0>65) had much higher odds of using the blood pressure (OR=2.815, CI=2.317-3.420 ) and cholesterol (OR=3.190, CI=2.396-4.!
249 ) preventive services. Males had much lower odds of getting blood pressure (OR=0.350, CI=0.318-0.384) and cholesterol (OR=0.597, CI=0.516-0.692) checks done compared to females. Odds of utilization were nearly similar for all races. Uninsured had lower odds for blood pressure (OR=0.282, CI=0.253-0.315) and cholesterol (OR=0.314, CI=0.262-0.376) use compared to privately insured people.
CONCLUSIONS: Overall MEPS respondents adhered to blood pressure and cholesterol check up guidelines. The study was however successful in identifying existing age, race, income, insurance status related disparities in US population.
Predicting Trends in Preventive Care Service Utilization Impacting Cardiovasc...gpartha85
This study aimed to characterize patterns of preventive care service utilization for cardiovascular disease and predict trends in a U.S. population using national health survey data. Descriptive analyses found high utilization of blood pressure and cholesterol screening across populations. Logistic regression identified factors associated with screening, such as women and Asians being less likely than men and other races to receive screenings. The results can help guide policies to reinforce screening guidelines for underserved groups.
Similar to International Journal of Cardiovascular Diseases & Diagnosis (20)
A 5-year old boy, with an established diagnosis of a topic
dermatitis, previously treated by topical corticosteroids and emollient cream with a good improvement, developed widespread papules on his legs, hands and forearm that appeared 5 months ago.
Methods: Retrospectively, the file records of the patients who underwent sleeve gastrectomy were examined. Demographic features, Body Mass Index (BMI), the mouth opening, Mallampati score, thyromental distance, sternomental distance, neck circumference measurements and videolaryngoscopic examination results were recorded Results: In a total of 140 consecutive patients (58 male, 82 female) were included in the study. The mean age of the study participants was 35.40 ± 9.78 and the mean BMI of the patients was 44.33 ± 7.52 kg/m2
. The mean mouth opening of the patients was 4.82 ± 0.54 cm
and the mean neck circumference was 43.52 ± 4.66 cm. The mean thyromental distance was 8.02 ± 1.00 cm and the mean sternomental distance was16.58 ± 1.53 cm. Difficult intubation was determined in 8 (5.7%) patients. In logistic regression analysis, age (p : 0.446), gender (p : 0.371), BMI (p : 0.947), snoring (p : 0.567), sleep apnea (p : 0.218), mouth opening (p : 0.687), thyromental distance (p :0.557), sternomental (p : 0.596) and neck circumference (p : 0.838) were not the independent predictors of difficult intubation. However, Mallampati score (p : 0.001) and preoperative direct laryngoscopy findings (p : 0.037) performed in outpatient clinic were the significant
predictors of difficult intubation. Interestingly, all patients with grade 4 laryngoscopy findings had difficult intubation.
Introduction: Laparoscopic surgery has been performed in Mexico since 1989, but no reports about training tendencies exist. We conducted a national survey in 2015, and here we report the results concerning training characteristics during the surgical residence of the respondents. Materials and Methods: A prospective study was conducted through a survey questioning demographic data, laparoscopic training during pre and post surgical residency and other of areas of laparoscopic practice. The sample was calculated and survey piloted before
application. Special interest in this report was placed on type and quality of training received. Data are reported in percentages.
Heterotopic Ossification (HO) is defined as pathological bone formation at locations where bone normally does not exist. The
presence of HO has been found to be a rare complication after stroke in several studies, whereas there are only sporadic references relating HO to Cerebral Palsy (CP) and few for CP and stroke. No effective treatment for HO has yet been found, whereas the cellular and molecular mechanisms have not been completely understood. Therefore, increased awareness among physicians is required, as a challenge for early diagnosis and treatment. A case of a male patient with CP, who developed HO on the paretichip joint following an ischemic stroke is presented.
Objectives: To assess the practice of food hygiene and safety, and its associated factors among street food vendors in urban areas of Shashemane, West Arsi Zone, Oromia Ethiopia, 2019.
Methods: Cross-sectional study design was applied from December 28, 2019 to January 27, 2020. Data was collected from 120 food handlers, which were selected by purposive sampling techniques. Information was gathered from interview and field observation by conducting food safety survey and using questionnaires via face to face interview. The collected data was entered using Epi Data 3.1 and finally, it was analyzed using SPSS VERSION 20.
A Division I football player experienced acute posterior leg pain while playing. An ultrasound examination revealed an unusual injury - a complete rupture of the plantaris tendon mid-substance. This type of isolated plantaris tendon injury has rarely been reported. Ultrasound was useful for diagnosis and guided rehabilitation by monitoring healing over time. The athlete was able to return to full competition within 3 weeks through a progressive rehabilitation program focused on restoring range of motion and strength. This case suggests isolated plantaris tendon injuries may allow for faster return to play than other potential causes of posterior leg pain.
Type 1 Diabetes (T1D), is a severe disease, representing 5-10% of all reported cases of diabetes worldwide. Fulminant Type 1 Diabetes Mellitus (FT1D) is a subtype of type 1 diabetes mellitus that is largely characterized by the abrupt onset of Diabetic Ketoacidosis (DKA) and severe hyperglycemia without insulin defi ciency. Viral infections have been hypothesized to play a major role in the pathogenesis of Fulminant Type 1 Diabetes Mellitus (FT1D) through the complete and rapid destruction of pancreatic beta cells. Coxsackie viral infection has been detected in islets of 50% of the pancreatic tissue recovered from recent-onset Type 1 Diabetes (T1D) patients. In this report we have highlighted a case where the patient developed a Group B Coxsackie virus infection culminating in the development of Fulminant Type 1 Diabetes Mellitus (FT1D).
Methods: Cercariae are released by infected water snails. To determine the occurrence of cercariae-emitting snails in SchleswigHolstein, 155 public bathing places were visited and searched for fresh water snails. Family and genus of the collected snails were determined and the snails were examined for the shedding of cercariae, using a standard method and a newly developed method.
Objective: To generate preliminary information about of enteroviruses and Enterovirus 71 (EV71) in patients with aseptic meningitis in Khartoum State, Sudan.
Method: Cerebrospinal fluid specimens were collected from 89 aseptic meningitis patients from different Khartoum Hospitals
(Mohammed Alamin Hamid Hospital, Soba Teaching Hospital, Omdurman Military Hospital, Alban Gadeed Teaching Hospital and Police Hospital) within February to May 2015. Among these 89 patients, 43 (48%) were males and 46 (52%) were females. The patient’s age ranged between 1 day and 30 years old. The collected specimens were assayed to detect enteroviruses and EV71 RNA using Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) technique
Femoral hernias, comprise 2% to 4% of all hernias in the inguinal region, and occur most commonly in women. Th ey present typically with a mass below the level of the inguinal ligament. The sac may contain preperitoneal fat, omentum, small bowel, or other structures and have a high rate of incarceration and strangulation due to the small size of the hernia neck orifice, requiring emergency surgery. We present the case of a 54-year-old female patient with intestinal occlusion due to incarcerated femoral hernia, repaired by laparoscopic approach, that gave the patient the opportunity to attend her daughter’s wedding the same day.
Small Supernumerary Marker Chromosome (sSMC) is a rare genetic condition marked by the presence of an extra chromosome to the 46 human chromosomes. This case report describes a 4 year old child with SSMC on the 46th chromosome. The child presented with delayed speech and language development, seizures and mild developmental delay. Speech and Language evaluation was carried out and management options are discussed.
A catheter is a thin tube made from medical grade materials that serve a broad range of functions, but mainly catheters are medical devices that can be inserted in the body to treat disease or perform surgical procedures. Catheters have been inserted into body cavities, ducts, or vessels to allow for drainage, administration of therapeutic fluids or gases, operational access for surgery. Catheters help perform tasks in various systems such as cardiovascular, urological, gastrointestinal, neurovascular, and ophthalmic systems. A dataset of 12 patients with varying “weights” and “heights” was recorded along with the lengths of their catheter tubes. This data set was found from two revered statistical textbooks on linear regression and the Department of Scientific Computing at Florida State University. This data set was not able to be linked to any particular clinical or experimental research studies, but the data set can be used to help catheter manufacturers and medical professionals better decide on what particular catheter lengths to use for patients knowing only their height & weight. These research insights could be helpful to healthcare professionals that have patients with incomplete or no healthcare records
to decide what catheter length to use. The main investigative inquiry that needed to be answered was how does patient weight & height influence catheter length together and separately? We conducted linear regression and other statistical analysis procedures in R program & Microsoft Excel and discovered that this data exhibited a quality called multi collinearity. With multi collinearity, all predictors (2 or more
independent variables) are not significant in an all encompassing linear aggression, but the predictors might be significant in their own individual linear regressions. Individual linear regression analyses were conducted for both patient height & weight to see how much they both contribute to varying catheter length. Patient weight was found to be more impatful than patient height in relationship to catheter length, even though height and weight are a classical example of multi collinearity predictors.
Bovine mastitis has a negative impact through economic losses in the dairy sector across the globe. A cross sectional study was carried out from September 2015 to July 2016 to determine the prevalence of bovine mastitis, associated risk factors and isolation of major causative bacteria in lactating dairy cows in selected districts of central highland of Ethiopia. A total of 304 lactating cows selected randomly from five districts were screened by California Mastitis Test (CMT) for subclinical mastitis. Based on CMT result and clinical examination, over all prevalence of mastitis at cow level was 70.62% (214/304).
Two hundred fourteen milk samples collected from CMT positive cows were cultured for isolation of major causative bacteria. From 214 milk samples,187 were culture positive and the most prevalent isolates were Staphylococcus aureus 42.25% (79/187) followed by Streptococcus agalactiae 14.43%
(27/187). Other bacterial isolates were included Coagulase Negative Staphylococcus species 12.83% (24/187), Streptococcus dysgalactiae 5.88% (11/187), Escherichia coli 13.38% (25/187) and Entrococcus feacalis 11.23% (21/187) were also isolated. Moreover, age, parity number, visible teat abnormalities,husbandry practice, barn fl oor status and milking hygiene were considered as risk factors for the occurrence of bovine mastitis and they were found significantly associated with the occurrence of mastitis (p < 0.05). The findings of this study warrants the need for strategic approach including dairy extension that focus on enhancing dairy farmers’ awareness and practice of hygienic milking, regular screening for subclinical mastitis, dry cow therapy and culling of chronically infected cows.
A 36-year-old female developed right upper quadrant pain and nausea after taking the herbal supplement kratom for two weeks to manage back pain. Laboratory tests showed elevated liver enzymes. A liver biopsy ruled out other causes and determined she had drug-induced liver injury from kratom use. Her symptoms and liver enzymes gradually returned to normal over six weeks after stopping kratom. The case report discusses kratom's potential for hepatotoxicity and advises clinicians to consider its effects on patient health.
The assessment, diagnosis and treatment of critically ill patients is extremely challenging. Patients often deteriorate whilst being
reviewed and their rapidly changing pathophysiology barrages healthcare professionals with new data. Furthermore, comprehensive assessments must be postponed until the patient has been stabilised. So, important data and interventions are often missed in the heat of the moment. In emergency situations, suboptimal management decisions may cause signifi cant morbidity and mortality. Fortunately, standardisation and careful design of documentation (i.e. proformas and checklists) can enhance patient safety. So, I have developed a series of checklist proformas to guide the assessment of critically ill patients. These proformas also promote the systematic recording and presentation of information to facilitate the retrieval of the precise data required for the management for critically ill patients. The proformas have been modifi ed extensively over the last twenty years based on my personal experience and extensive consultation with colleagues in several world-renowned centres of excellence. The proformas were originally developed for use in the intensive therapy unit
or high dependency unit. However, they have been adapted for use by outreach teams reviewing patients admitted outside of critical care areas. The use of these tools can direct eff orts to provide appropriate organ support and provides a framework for diagnostic reasoning.
This review article discusses microvascular and macrovascular disease in systemic hypertension. It summarizes that:
1) Cardiac imaging plays a crucial role in risk stratifying hypertensive patients and identifying management strategies by properly diagnosing microvascular and coronary artery disease.
2) The nitric oxide synthase (eNOS) G298 gene allele may be a marker for microvascular angina in hypertensive patients, as studies have found it to be more prevalent in hypertensive patients with chest pain and reversible myocardial defects but normal coronary arteries.
3) Both structural changes like capillary rarefaction and functional changes like endothelial dysfunction can cause microvascular dysfunction and angina in hypertensive individuals in the absence of
This study characterized dengue infections in Pakistan by analyzing hematological and serological markers in 154 suspected dengue cases and 146 control patients with other febrile illnesses. NS1 antigen was detected in 55% of dengue cases, IgM antibodies in 30%, and both in 15%. Control groups primarily had malaria (71%) and enteric fever (20%). Hematological markers (platelet count, hematocrit, WBC) measured before and after treatment showed significant differences for platelet count and hematocrit but not WBC count between the groups. Analysis of clinical symptoms and serological/hematological markers helps diagnose dengue, assess prognosis, and inform prevention efforts to reduce morbidity, mortality and spread of the disease.
Researchers from Utrecht recently published yet another paper on the use of Magnetic Resonance Imaging (MRI)demonstrating an additional failed attempt to understand the importance of qualitative versus quantitative imaging, and anatomic versus physiologic imaging. Th e implications of this failure here cannot be overstated.
Introduction: Stroke is an even more dramatic major public health problem in young people. Goal of the study: Contribute to the knowledge of strokes in young people. Methodology: This was a retrospective study carried out over a period of 02 years (January 2017 to December 2018) including the files of patients aged 18 to 49 years hospitalized for any suspected case of stroke in the Neurology department of the University Hospital
Center of the Sino-Central African Friendship (CHUSCA) of Bangui.
Background: This report describes a unique case of a patient that developed psychotic symptoms believed to be secondary
to a tentorial meningioma with associated hydrocephalus. These psychotic symptoms subsequently abated with placement of a
ventriculoperitoneal shunt. Case description: 60-year-old female was admitted to an inpatient psychiatric facility on a psychiatric involuntary commitment petition due to progressive paranoia, homicidal ideation and psychosis. The work up showed a calcified six cm tentorial meningioma with associated hydrocephalus. The patient initially rejected treatment but later became amenable to placement of Ventriculoperitoneal Shunt
(VPS).
More from SciRes Literature LLC. | Open Access Journals (20)
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
2. SCIRES Literature - Volume 3 Issue 1 - www.scireslit.com Page - 0016
International Journal of Cardiovascular Diseases & Diagnosis
ABSTRACT
Introduction: African-Americans with heart failure are known to have higher mortality and morbidity rates compared to other races
with a variable response to therapies. There is a paucity of race-specific data on the benefit of Cardiac Resynchronization Therapy with
Defibrillator (CRT-D) in patients with heart failure with reduced ejection fraction.
Objectives: Our study was designed to look at the pattern of response to CRT-D in African-American subset and determine predictors
of recovery of left ventricular function.
Material and methods: Records of 212 patients with CRT-D at Albert Einstein Medical Center, Philadelphia between 2009 and 2013
were analysed for baseline, electrocardiogram, and echocardiogram characteristics. The African American (AA) cohort (n = 130) was
compared with a Non-African American (Non-AA) group (n = 82) with respect to clinical outcomes and echocardiographic LV recovery.
Results: Improvement in LVEF by ≥5% from base line (primary outcome) was observed to be similar in both African-American and
Non-African American groups (63% vs. 59.76%; p-value-0.71). The secondary clinical outcomes including major cardiac events, Inotropic
dependence, number of total HF exacerbations, admissions, Telemetry/ICU admissions in 30 days, number of ICD shocks and ATP,
2-year mortality and event–free survival were comparable between the groups.
Conclusion: African-Americans with advanced heart failure showed response to CRT therapy similar to non-African American races.
Among the AA, those with poor baseline ejection fraction and dilated left ventricle (LVEDD >6cm) were associated with less favourable
response with CRT-D and this subset of patients should therefore be considered early for advance heart failure therapies such as
ventricular assist devices or cardiac transplant.
Keywords: Cardiac resynchronisation therapy; Clinical outcomes; Heart failure; Race/ethnicity; African-Americans
INTRODUCTION
Over last 15 years, CRT has been proven to relieve symptoms,
reduce the need for recurrent hospitalizations, improve quality
of life, and reduce morbidity and mortality in patients with heart
failure with reduced ejection fraction and wide QRS duration [1-5].
The REVERSE trial and MADIT-CRT found that these benefits can
also be seen in less advanced stages of heart failure [6]. However,
it is unclear whether race plays a role in response to CRT therapy.
African-Americans (AA) with heart failure are known to have higher
mortality and morbidity rates compared to other races are known to
have differential response to several cardiac drugs [7]. It is unknown
if AA may respond differently to CRT therapy. There is a paucity of
race-specific studies in this area. Moreover, under-representation of
certain racial/ethnic minorities in most trials raises questions about
the rationale to adopt device recommendations uniformly in all races
[8]. IMPROVE HF registry comprising of 8936 eligible heart failure
patients, the mortality benefit was equivalent in white and black
and other minority races. The authors suggested that race/ ethnicity
should not be a factor for decision on device therapy for heart failure
[9].
The objective of this study is to assess the proportion of responders
to CRT-D therapy in African American patients compared to a non-
African American population and to evaluate the clinical correlates of
left ventricular recovery in African American patients.
MATERIALS AND METHODS
This retrospective study was designed as a single centre study
at Albert Einstein Medical Center, Philadelphia, USA. A database
maintained at by the implantable cardiac device clinic of AEMC
was used and the records of the patients with known diagnosis of
heart failure that had undergone CRT-D between 1st January 2009
to 31st December 2013 were screened. All adults (>18 years) of both
sexes and of any race, diagnosed to have congestive heart failure of
any cause, with LVEF ≤35% on echocardiogram and if ECG showed
QRS > 120 msec were included for the study. Those not completing
24-month follow-up or having any documented non-compliance
with medications, inadequate echocardiographic data and those
with history of ongoing chemotherapy for active malignancies were
excluded. Institutional Review Board approval was obtained for the
conduct of the study along with waiver of consent from participants
as the study employed only a retrospective chart-review method.
The primary outcome was the proportion of echocardiographic
responders to CRT-D therapy in African American compared to other
races at 2 years follow-up. The median time to echo used in study for
assessing response was 303 days (Interquartile range 203-412 days).
The secondary outcomes included number of hospitalizations in the
subsequent 30 days and 2 years following implantation, ICD shocks
and major cardiovascular events including acute coronary syndrome,
stroke, cardiac surgery, LVAD, Cardiac transplant or cardiac arrest.
Outcomes were measured over an average follow up at 24 months.
Any differences in clinical or echocardiographic parameters in
African-American vs. Non-African-American subsets were compared
and analysed.
Echocardiographic responders: Echocardiographic studies done
as per American Society of Echocardiography recommendations. An
improvement in LVEF of at least 5% was taken as echocardiographic
response and those who those who normalized EF to ≥50% were
considered super-responders.
The 3-month data was taken as short-term and 24-month data
was taken as long-term for the analysis. Age, BMI, presence of DM/
hypertension, significant CKD, QRS duration, LBBB or otherwise,
pre-procedural LVEF, LA dimension, significant MR, RV dilatation,
occurrence of ICD shocks or VT episodes are tested as possible
predictors for response.
Statistical methods
Clinical data, medical history, medications, laboratory
values, echocardiographic parameters were analysed. Significant
improvement was defined as an increase in ejection fraction
of at least 5% above the pre-CRT echocardiographic value.
Continuous variables were represented as mean and standard
deviation. Categorical variables were represented as frequencies
and percentages. The statistical significance in the difference in the
outcome variables between the groups and was assessed t-test and
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International Journal of Cardiovascular Diseases & Diagnosis
Chi-square test, respectively. For studying intersubject variation
in echocardiographic parameters over time post CRT, we used the
paired t-test and McNamara’s test for continuous and categorical
variables respectively. Among the responders, a univariate analysis of
possible predictors was evaluated. A multivariate model was created
to assess for predictors of echocardiographic response using binary
logistic regression and consisted of patient characteristics, EKG
characteristics, comorbidities, echocardiographic parameters and
underlying function NYHA class. The multivariate was repeated to
assess for predictors of super-response compared to non-responders.
P-value of <0.05 was taken to infer statistical significance. Data was
analysed using SPSS V23.0 (Armonk, NY).
RESULTS
The Device clinic records at AEMC were screened and all patients
with a diagnosis of heart failure who had undergone CRT in the last
5 years were selected. After applying the inclusion and exclusion
criteria, there were 212 patients who had at least two-year follow-up
data. Of them, 130 belonged to African-American race (AA group).
The remaining 82 were grouped together as NAA group that included
49 Caucasians, 9 Asians, and 24 Hispanics.
Baseline characteristics
The base-line and clinical characteristics of the study population
is given in table 1. The mean age and BMI were similar in both groups.
Although males predominated in both groups, there are significant
differences in the prevalence of male sex and ischemic heart disease
in the NAA group. Smokers, alcoholics, hypertensive, diabetics and
dyslipidaemia, chronic kidney disease was of similar proportions. The
use of guideline directed medications for heart failure was similar in
both groups. The NYHA class, the BP and heart rate and the ECG
parameters were comparable in both groups. Pre-procedural ECHO
parameters were similar in both groups [mean LVEF being 22.11 ±
8.19 vs. 24.65 ± 7.34 Mean LV ESD 5.05 ± 0.91 vs. 4.9 ± 0.85 cm and
mean LV EDD 5.9 ± 0.82 vs. 5.83 ± 0.82 cm] (Table 2).
Primary outcome
The degree of increase in mean LVEF or reduction in mean LV
dimensions was similar in AA (n = 130) and NAA (n = 82) groups. It
was noted that response to CRT was similar irrespective of presence
or absence of atrial fibrillation (Table 2). There were 81 [38.2%]
non-responders of which 48 subjects (37.7%] were AAs and 33
subjects [40.2%] were non-AAs, p = 0.83. There was no significant
difference in the response rates in AA and NAA groups [82(62.3%) vs.
49(59.76%); p-value-0.83] (Table 3). Super-responders were similar
in both groups: 17.7% and 14.6% in AA and NAA respectively.
Additionally, it was observed that there was only a negligible decrease
in LV dimensions, but the occurrence of significant MR lessened
following CRT implantation in both groups (Table 2).
Clinical outcomes
The major secondary clinical outcomes such as Inotropic
dependence, HF admissions to Telemetry/ICU admissions in 30 days,
number of ICD shocks and Anti-tachycardia pacing and VT episodes
found on interrogation were comparable in both groups (Table 4).
The rate of In-hospital mortality and all-cause Mortality within 2
years were also similar in the two groups.
Of the 130 patients in the AA group, 12.3% died by 2 years. All
cause mortality at 2 years in NAA group (82 patients) was 11% (Table
4). Of the 114 African-Americans that were alive, 86 patients had
clinical events such as HF exacerbations, ICD shocks/ATPs, ACS,
stroke, LVAD/Cardiac transplant, inotropic dependence (75.4%). The
corresponding number in the NAA group was 65 out of 73 (89.04%).
Predictors of response
Several possible predictors influencing the positive response were
evaluated by univariate and multivariate analysis (Table 5 & 6). Age,
BMI, presence of DM/hypertension, significant CKD, QRS duration,
LBBB or otherwise, pre-procedural LVEF, LA dimension, significant
MR, RV dilatation, or occurrence of ICD shocks did not predict
the responders in AA or NAA groups. Men had better response
than women especially in NAA group while AA group has not
Table 1: Baseline characteristics of the study population.
Variable
African American
(n = 130)
Non-African
American
(n = 82)
p-value
Age in years (Mean ± SD) 66.2 ± 11.8 66.3 ±11.8 0.92
Body mass index (kg/m2
)
(Mean ± SD)
29.99 ± 8.11 29.42 ± 7.29 0.60
Male sex (no. %) 71 (54.62%) 61 (74.39%) <0.01
Etiology: Ischemic 45 (34.62%) 47 (57.32%) <0.01
NYHA functional class - II
III
IV
51 (39.23%)
50 (38.46%)
29 (22.3%)
33 (40.24%)
40 (48.78%)
09 (10.97%)
0.08
Hypertension (Blood pressure
140/90 mm Hg or above
or use of antihypertensive
medications)
128 (98.46%) 79 (96.34%) 0.32
Diabetes mellitus 69 (53.08%) 50 (60.98%) 0.25
Hyperlipidemia 109 (83.85%) 71 (86.59%) 0.58
Smoker, current 46 (35.38%) 26 (31.71%) 0.58
Alcohol use, current 25 (19.23%) 15 (18.29%) 0.92
Drug abuse, current 17 (13.08%) 8 (9.76%) 0.44
CKD stage III and above 30 (23.07%) 21 (25.61%) 0.67
SBP (mm Hg) (Mean ± SD)
DBP (mm Hg) (Mean ± SD)
Heart rate (beats per minute)
(Mean ± SD)
129.92 ± 18.1
76.41 ± 9.51
78.58 ± 9.87
129.2 ± 16.47
75.38 ± 12.17
79.89 ± 12.37
0.77
0.49
0.39
EKG: Atrial fibrillation/flutter
Mean QRS> 150 msec (Mean
± SD)
PR (msec) (Mean ± SD)
QTc (Mean ± SD)
LBBB (Mean ± SD)
47 (36.15%)
142.65 ± 27.22
167.09 ± 49.46
493.3 ± 45.12
62 (47.6%)
28 (34.15%)
151.45 ± 27.7
167.09 ± 49.4
493.11 ± 43.57
38 (46.34%)
0.76
0.02
0.85
0.97
0.96
Mean LVEF (%)
Mean LVESD (cm)
Mean LVEDD (cm)
Left atrial dimension (cm)
Mitral regurgitation (moderate
to severe)
Right ventricle dilatation
22.10 ± 8.18
5.05 ± 0.91
5.92 ± 0.84
4.54 ± 0.72
37 (28.46%)
41 (32.28%)
24.65 ± 7.34
4.90 ± 0.88
5.83 ± 0.80
4.65 ± 1.00
21 (25.61%)
29 (35.36%)
0.02
0.25
0.46
0.36
0.65
0.62
Diuretics
ACEI/ARBs
Beta-blockers
Spironolactone
Hydralazine/nitrates
Digitalis
Statins
130 (100%)
115 (88.5%)
130 (100%)
64 (49.23%)
129 (99.23%)
29(22.31%)
109(83.8%)
82 (100%)
70 (87.5%)
81(98.7%)
27 (32.93%)
64 (78.05%)
14(17.07%)
71(86.59%)
0.99
0.70
0.19
0.02
<0.01
0.35
0.58
CKD: Chronic Kidney Disease; SBP: Systolic Blood Pressure; DBP: Diastolic
Blood Pressure; EKG: Electrocardiogram; LLVEF= Left Ventricular Ejection
Fraction; LVEDD= Left Ventricular End-Diastolic Dimension; LVESD= Left
Ventricular End-Systolic Dimension.
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International Journal of Cardiovascular Diseases & Diagnosis
shown similar phenomenon. In the subgroup multivariate analysis
performed for super-responders, only LVEDD of ≥6 cm predicted
lower chance of being a super-responder (aOR 0.10, 95% CI 0.02-
0.38; p = 0.001).
Survival data
The mortality at 30-days and 2 years were not significantly
different in AA and NAA groups.
DISCUSSION
Cardiac Resynchronization therapy for advanced systolic heart
failure is evidence-based and widely practiced strategy. MADIT-I
and MADIT-II established the use of prophylactic ICD in ischemic
cardiomyopathy in early 2000s. CRT therapy gained importance
after its clinical benefits of improvement of symptoms and exercise
capacity as well as marked reduction in hospitalisations in HF
patients were realised subsequently [2]. Following CRT, reverse
ventricular remodelling was found consistently at 6-month follow-
up with up to 15% reduction in echo derived LVEDD and about 6%
increase in LVEF more so in the non-ischemic Cardiomyopathy [8].
Reduction in hospitalisation for CV events and mortality benefit was
proven in subsequent trials including the CARE-HF and MADIT-
CRT trials, the latter showing about 34% relative risk reduction
in mortality [10,11]. The benefits of CRT/CRT-D to improve the
outcomes in chronic heart failure were proven without ambiguity
and it entered various heart failure guidelines endorsing it as class I
recommendation for select patients [12,13]. Despite this data, large
cohorts of African American patients have not been widely studied.
Based on previous studies in other areas of cardiology, there is
a concern that AAs may respond differently to CRT compared to
non-AA cohort. Heart failure is more prevalent in African American
population, occurs at early age and is more severe than that is seen in
Table 2: Echocardiographic response in each group.
Variable Pre CRT-D Post CRT-D p-value
African
American
(n = 130)
LVEF (%) 22.11 ± 8.19 32.02 ± 14.24 <0.01
LVESD (cm) 5.05 ± 0.91 4.65 ± 1.27 <0.01
LVEDD (cm) 5.92 ± 0.84 5.72 ± 1.09 0.01
Moderate-severe
MR (%)
37(28.4%) 20(15.3%) <0.01
Non-African
American
(n = 82)
LVEF (%) 24.66 ± 7.34 32.34 ± 12.71 <0.01
LVESD (cm) 4.9 ± 0.88 4.66 ± 1.11 0.02
LVEDD (cm) 5.83 ± 0.80 5.79 ± 0.92 0.54
Moderate-severe
MR (%)
21(25.6%) 13(15.8%) 0.13
CRT-D: Cardiac Resynchronization Therapy Defibrillator; LVEF: Left Ventricular
Ejection Fraction; LVESD: Left Ventricular End Systolic Diameter; LVEDD: Left
Ventricular End Diastolic Diameter; MR: Mitral Regurgitation.
Table 3: Echocardiographic super-responders, responders and non-responders
in both groups.
Variable
African American
(n = 130)
Non-African
American
(n = 82)
p-value
Overall
Non-responder (%)
Responder (%)
Super-responder (%)
37.7
44.6
17.7
40.2
45.1
14.6
0.83
Sinus Rhythm
Non-responder (%)
Responder (%)
Super-responder (%)
32.5
49.4
18.1
40.7
48.1
11.1
0.43
Atrial fibrillation/flutter
Non-responder (%)
Responder (%)
Super-responder (%)
46.8
36.2
17.0
39.3
39.3
21.4
0.79
Table 4: Secondary outcomes in study groups.
Variables
African
American
Non-
African
American
p-value
Inotrope dependence (%) 3.1 2.5 0.79
Readmission to cardiovascular service
within 30-days (%)
16.9 19.5 0.63
Readmission to cardiovascular service
within 2-years (%)
66.9 65.9 0.87
Readmission for acute HF exacerbation
within 2-years (%)
37.7 45.1 0.28
Experienced ICD shock pacing within
2-years (%)
16.2 12.2 0.42
Anti-tachycardia pacing within 2-years (%) 20 15.9 0.44
At least one major cardiac event* within
2-years* (%)
23.1 13.4 0.08
In-hospital mortality within 2-years (%) 6.2 4.9 0.69
All-cause mortality at 2-years (%) 12.3 11.0 0.77
*
Composite event consisting of at least one of the following: Acute Coronary
Syndrome; Stroke; Cardiac Surgery; Left Ventricular Assist Device Placement;
Heart Transplant; Cardiac Arrest.
Table 5: Univariate predictors of response to CRT therapy within multivariate
model.
Non-responder
(n = 82)
Responder
(n = 130)
p-value
African American race (%) 59.8 62.3 0.71
Age in years 66.5 ± 11.8 66.0 ± 11.6 0.75
Female sex (%) 32.9 40.8 0.25
Body mass index ≥30kg/
m2
(%)
40.2 44.6 0.53
EKG parameters (%)
Baseline LBBB
Baseline RBBB
Baseline IVCD
42.7
17.1
40.2
50.0
10.8
39.2
0.35
Diabetes (%) 61 53.1 0.25
Hypertension (%) 97.6 97.7 0.95
Hyperlipidemia (%) 90.2 81.5 0.08
Non ischemic
Cardiomyopathy (%)
50 60.8 0.12
Atrial fibrillation or flutter (%) 40.2 32.3 0.23
Current smoker (%) 35.4 33.1 0.73
Current alcohol use (%) 24.4 15.4 0.10
Current drug abuse (%) 13.4 10.8 0.56
Left Ventricular ejection
fraction (%)
24.6 ± 7.3 22.1 ± 8.1 0.02
LVEDD ≥6cm (%) 54.9 40.0 0.03
Moderate to severe mitral
regurgitation (%)
22.0 30.8 0.16
NYHA functional class (%)
Class II
Class III
Class IV
42.7
41.5
15.9
37.7
43.1
19.2
0.71
LBBB: Left Bundle Branch Block; RBBB: Right Bundle Branch Block; IVCD:
Intraventricular Conduction Delay; LVEDD: Left Ventricular End Diastolic
Diameter; NYHA: New York Heart Association.
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the whites [14,15]. The annual incidence of heart failure in whites is
approximately 6 per 1,000-person years, while in African Americans
it is 9.1 per 1,000 person-years [14]. In CARDIA (Coronary Artery
Risk Development in Young Adults), study in persons <50 years, 26
out of 27 incident heart failure belonged to AA race [14,15]. In a long
follow-up studies –ARIC and MESA, after statistical adjustment for
established risk factors, the discrepancies between the AA and Whites
persisted in the women but not in men. In those with young age at
onset discrepancy was more evident [16,17].
Bibbins-Domingo et al reported that heart failure before age 50
was 20 times more frequent in African Americans than in whites [15].
Some studies have reported higher rates of hospitalizations in the
African American cohort [18,19]. This could be probably explained
by higher prevalence of hypertension, diabetes and obesity in these
races. The disparities in the outcomes in African-Americans following
various therapies in HF can be multi-factorial and may involve an
interplay of environment, social factors and genetic composition
[20]. The influence of gene polymorphism on LV reverse remodelling
following CRT is not fully understood and still evolving. Genetic
variations in salt-sensitivity and response to RAS blockade have
been identified in cardiac patients. AASK study had shown that AA
who were homozygous for the ACE polymorphism responded well
to ACE inhibitors but not to CCBs compared to those heterozygous
[21]. Nishio K et al demonstrated that the higher incidence of ACE
related adverse effects in AA is due to ACE enzyme and bradykinin
gene polymorphism [22,23].
In another study, Pezzali and Curnis found that Glu27Glu
carriers (ARs gene polymorphism) showed greater LV reverse
remodelling after CRT and lesser incidence of malignant ventricular
tachyarrhythmias [24].
Most heart failure trials included about 20% African Americans
and they have never been studied exclusively, except in the African
American Heart failure trial [AHeFT] testing Isosorbide dinitrate/
hydralazine. Several major trials like CARE-HF, MIRACLE-ICD,
MADIT-CRT and CHAMPIAN trials have proven to improve clinical
outcomes and some recovery of LV systolic function following CRT
therapy. However, these data included heterogenous population
and African American cohort were not widely studied in these CRT
trials and sub-group analysis are limited [25]. In a recent analysis
(IMPROVE HF registry) the use of CRT therapy was associated
with reduced 24- month mortality in African-Americans which was
comparable to other races [9].
This study was undertaken, in view of paucity of literature on the
response to CRT-D in African-American heart failure patients. Our
study comprised of 130 AA patients constituting about 61% of the
cohort, a substantially larger representation than most traditional
studies. We found that African-Americans had a similar response
to CRT-D therapy as compared to the non-African American
patients. The degree of increase in mean LVEF or reduction in mean
LV dimensions was similar in AA and NAA groups. The clinical
outcomes such as major cardiac events (ACS, stroke, LVAD/Cardiac
transplant of other cardiac surgeries), inotropic dependence, number
of total HF exacerbations, admissions, telemetry/ICU admissions
in 30 days, number of ICD shocks and ATP, VT episodes found on
interrogation were comparable in both groups. Rates of in-hospital
mortality and all-cause mortality within 2 years were similar in the
two groups.
All patients in our study were on goal directed therapy and several
possible predictors influencing the positive-response or super-
response were evaluated. Age, BMI, presence of DM/hypertension,
significant CKD, QRS duration, LBBB or otherwise, LA dimension,
significant MR, RV dilatation, occurrence of ICD shocks or VT
episodes did not predict the response or super-response in AA or
NAA groups.
In the multivariate analysis, although female sex and LBBB
trended to benefit from CRT-D, surprisingly NICM increased hazard
ratio and AF reduced it. The wide confidence interval could be due to
low study numbers. It is unclear why we NICM increased the hazard
ratio and atrial fibrillation reduced it.
Irrespective of race, subjects with poor baseline ejection fraction
and dilated left ventricle (LVEDD >6cm) were associated with less
favourable response with CRT-D and this subset of patients should
therefore be considered early for advance heart failure therapies such
as ventricular assist devices or cardiac transplant.
A small prospective study on 75 patients followed for 17.9
months following CRT therapy, identified that baseline QRS < 150
msec, > 40 msec of QRS shortening following CRT, and non-ischemic
etiology are important predictors for full response [26]. Goldenberg
analysed the MADIT-CRT database and identified that female sex,
non-ischemic origin, LBBB, QRS > 150 msec, prior hospitalisation for
HF, LVEDV> 125 ml/mt2 and LA volume >40ml/mt2 are the seven
Table 6: Predictors of response to CRT therapy within multivariate model.
Variable
Adjusted
Odds
Ratio
Lower 95%
Confidence
intervals
Lower 95%
Confidence
intervals
p-value
African American race 0.87 0.45 1.67 0.67
Age 1.00 0.97 1.03 0.89
Female sex 0.87 0.43 1.78 0.70
Body mass index ≥30kg/
sqm
1.73 0.86 3.46 0.12
Underlying RBBB versus
LBBB
1.67 0.65 4.28 0.29
Underlying IVCD versus
LBBB
1.38 0.53 3.61 0.51
Diabetes 0.81 0.43 1.54 0.52
Hypertension 2.08 0.23 18.96 0.52
Hyperlipidemia 0.47 0.18 1.27 0.14
Non ischemic
Cardiomyopathy
1.42 0.73 2.75 0.30
Atrial fibrillation or flutter 0.62 0.32 1.18 0.14
Current smoker 0.95 0.47 1.93 0.89
Current alcohol use 0.51 0.20 1.27 0.15
Current drug abuse 1.13 0.35 3.61 0.84
Left ventricular ejection
fraction
0.95 0.91 0.99 0.02
LVEDD ≥6cm 0.34 0.17 0.67 0.00
Moderate to severe
mitral regurgitation
1.54 0.74 3.23 0.25
NYHA functional class III
versus Class II
1.24 0.61 2.50 0.55
NYHA functional class IV
versus Class II
1.37 0.55 3.38 0.50
LBBB: Left Bundle Branch Block; RBBB: Right Bundle Branch Block; IVCD:
Intraventricular Conduction Delay; LVEDD: Left Ventricular End Diastolic
Diameter; NYHA: New York Heart Association.
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International Journal of Cardiovascular Diseases & Diagnosis
predictors that predict good response [11]. In MADIT-CRT trial,
1820 patients were followed for 2.4 years following ICD/CRT-ICD.
The primary end-point which was non-fatal heart failure or death
from any cause, was seen in 25.3% in ICD group and in 17.2% in the
CRT group. There was significant increase in LVEF and reduction
in LV volumes. Both ischemic and non-ischemic groups benefited
in the same way. Those with QRS width of > 150 msec responded
the best [6]. The long-term results of MADIT-CRT were also equally
promising with persistent benefits seen in the patients with mild
heart failure with LBBB regardless of sex, duration of QRS or cause of
cardiomyopathy [27].
In the IMPROVE HF registry comprising of 8936 eligible patients,
the 24-month mortality rate was evaluated in various races following
CRT-D/CRT-P therapy. Clinical benefit was seen with the therapy
with adjusted odds ratio of 0.64 for 24-month mortality. However,
the benefit was equivalent in white and black and other minority
races. The authors concluded that race/ ethnicity should not be a
factor for decision on device therapy for heart failure [9]. Our study
specifically focussed on this issue.
Rickard et al compared reverse ventricular remodelling and
long-term outcomes in 88 AAs versus 574 European Americans
with advanced heart failure on CRT. The survival and ventricular
remodelling were found to be similar in both groups [28]. In our
study we could add a greater number of AAs compared to Rickard’s
cohort.
STUDY-LIMITATIONS
This is a retrospective single centre study and therefore the
total sample size is limited. This study was spread over 5 years with
multiple operators doing the CRT-D and the echocardiographic
testing can add to the challenges. Hence the assessment of response
to CRT using the definition of improvement >5% of EF can have
some inherent fallacy. Of those excluded, patients were lost to follow-
up due to patient non-compliance for follow-up visits. This may be
due to the fact that the study centre mainly caters to the inner-city-
-population of north Philadelphia which comprises of about 40 %
African-Americans who belong to the lower economic strata of the
community.
CONCLUSIONS
African-Americans with advanced heart failure showed response
to CRT therapy similar to non-African American races in our
retrospective single centre study and the clinical outcomes at 2-year
follow-up were also comparable. There were no robust pre-procedural
predictors to predict the degree of response in any group. Subjects
with poor baseline ejection fraction and dilated left ventricle (LVEDD
>6cm) were associated with less favourable response with CRT-D
and this subset of patients should therefore be considered early for
advance heart failure therapies such as ventricular assist devices or
cardiac transplant.
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