A defined,plant‐based diet utilized in an outpatient cardiovascular clinic effectively treats hypercholesterolemia and hypertension and reduces medications

Background

Cardiovascular disease (CVD) is a major economic burden in the United States. CVD risk factors, particularly hypertension and hypercholesterolemia, are typically treated with drug therapy. Five‐year efficacy of such drugs to prevent CVD is estimated to be 5%. Plant‐based diets have emerged as effective mitigators of these risk factors.

Hypothesis

The implementation of a defined, plant‐based diet for 4 weeks in an outpatient clinical setting may mitigate CVD risk factors and reduce patient drug burden.

Methods

Participants consumed a plant‐based diet consisting of foods prepared in a defined method in accordance with a food‐classification system. Participants consumed raw fruits, vegetables, seeds, and avocado. All animal products were excluded from the diet. Participant anthropometric and hemodynamic data were obtained weekly for 4 weeks. Laboratory biomarkers were collected at baseline and at 4 weeks. Medication needs were assessed weekly. Data were analyzed using paired‐samples t tests and 1‐way repeated‐measures ANOVA.

Results

Significant reductions were observed for systolic (?16.6 mmHg) and diastolic (?9.1 mmHg) blood pressure (P < 0.0005), serum lipids (P ≤ 0.008), and total medication usage (P < 0.0005). Other CVD risk factors, including weight (P < 0.0005), waist circumference (P < 0.0005), heart rate (P = 0.018), insulin (P < 0.0005), glycated hemoglobin (P = 0.002), and high‐sensitivity C‐reactive protein (P = 0.001) were also reduced.

Conclusion

A defined, plant‐based diet can be used as an effective therapeutic strategy in the clinical setting to mitigate cardiovascular risk factors and reduce patient drug burden.

     

The effect of fasting status on lipids,lipoproteins, and inflammatory biomarkers assessed after hospitalization for an acute coronary syndrome: Insights from PROVE IT–TIMI 22

Background

For decades, fasting for 8 to 12 hours has been recommended for measurement of lipid profiles. The effect of fasting on low‐density lipoprotein cholesterol (LDL‐C) and triglycerides (TG) has been described in healthy cohorts and those with stable disease states. Recently, guidelines suggested that fasting may not be necessary due to its small effect on lipid measures. Little is known, however, regarding whether the impact of fasting is altered in the setting of an acute coronary syndrome (ACS).

Hypothesis

We hypothesized that the post‐ACS period would minimally effect the impact of fasting status on lipid measurements.

Methods

We evaluated the association of fasting on lipid and other biomarkers at the randomization visit, which occurred at a median of 7 days after the onset of an ACS, as well as during follow‐up, in a cohort of 4177 subjects from the Pravastatin or Atorvastatin Evaluation and Infection Therapy–Thrombolysis In Myocardial Infarction 22 (PROVE IT–TIMI 22) trial.

Results

Fasting samples were independently associated with a higher LDL‐C of 4.1 mg/dL and apolipoprotein‐B 100 of 2.6 mg/dL as well as a lower TG of 21.0 mg/dL and high‐sensitivity C‐reactive protein of 0.48 mg/dL. The relative difference was 3.8% for LDL‐C and ?11.3% for TG. Fasting did not change total cholesterol, high‐density lipoprotein cholesterol, apolipoprotein A‐I, lipoprotein(a), or apolipoprotein C‐III.

Conclusions

Although fasting does impact lipid measurements, the effect on LDL‐C is small (about 4 mg/dL), both early after ACS and during follow‐up. These data provide support for recent guidelines that no longer advocate for fasting lipid samples, including in the setting of ACS.

     

Improvement in clinical outcomes of patients with heart failure and active cocaine use after β‐blocker therapy

Background

Cocaine use has a high prevalence in the United States and can be associated with significant cardiovascular disease, even in asymptomatic users. β‐Adrenergic receptor hyperactivation is the underlying pathophysiologic pathway of cocaine cardiotoxicity. β‐Blocker therapy is controversial in patients with active cocaine use.

Hypothesis

β‐Blocker therapy is associated with clinical improvement in patients with heart failure despite active cocaine use.

Methods

In a single‐center, retrospective chart analysis, patients with newly diagnosed heart failure and active cocaine use who had been started on β‐blocker therapy were reviewed. The New York Heart Association (NYHA) functional class and the left ventricular ejection fraction (LVEF) were recorded at baseline and after 12 monthsnthsnths of β‐blocker use. Patients were excluded if they had been on prior β‐blocker therapy, had other reasons for volume overload, had chronic kidney disease stages G4 or G5, or had a life expectancy <12 months.

Results

Thirty‐eight patients were identified; most were African American males. A statistically significant improvement was found in both NYHA functional class (P < 0.0001) and LVEF (P < 0.0001) after 12 months of β‐blocker therapy. No major adverse cardiovascular events occurred in this population.

Conclusions

β‐Blocker use in cocaine users with heart failure with a reduced ejection fraction is associated with a lower NYHA functional class and a higher LVEF at 12‐month follow‐up. No major adverse cardiovascular events were observed.     

Low‐flow/low‐gradient aortic stenosis—Still a diagnostic and therapeutic challenge

Aortic stenosis (AS ) is the most frequently observed valvular heart disease. During the symptomatic stage, the rate of death increases dramatically, so that a precise diagnostic approach is taken to guide therapeutic options. Of patients with severe AS , 30% to 50% present with low‐flow/low‐gradient AS (LF /LGAS ) status. This review focuses on LF /LGAS and the best diagnostic and therapeutic management in either classic LF /LGAS with reduced left ventricular ejection fraction (LVEF ) or paradoxical LF /LGAS with preserved LVEF . Current literature demonstrates that in classic LF /LGAS it is crucial to rule out a pseudo‐severe AS , because reduced LVEF may result in an incomplete opening of the valve. This can be done by low‐dose dobutamine stress echocardiography. Classic LF /LGAS has poor clinical outcomes when managed conservatively; therefore, surgical or interventional aortic valve replacement should be performed. In paradoxical LF /LGAS , the LVEF is preserved (>50%), but impaired filling of the concentric hypertrophied ventricle leads to reduced stroke volume. Therefore, diagnostic and therapeutic decisions in paradoxical LF /LGAS are even more challenging. It is a heterogeneous disease entity, and it is crucial to rule out any diagnostic errors because numerous potential confounders might lead to misdiagnosis. As in classic stenosis, pseudo‐severe stenosis must be ruled out as well. Evaluation via multidetector computed tomography or transesophageal echocardiography can help to evaluate the morphologic alterations of the valve (eg, calcification). Further studies are necessary to understand this disease entity and to evaluate the optimal diagnostic and therapeutic approach for these patients.     

Study of young patients with myocardial infarction: Design and rationale of the YOUNG‐MI Registry

The YOUNG‐MI registry is a retrospective study examining a cohort of young adults age ≤ 50 years with a first‐time myocardial infarction. The study will use the robust electronic health records of 2 large academic medical centers, as well as detailed chart review of all patients, to generate high‐quality longitudinal data regarding the clinical characteristics, management, and outcomes of patients who experience a myocardial infarction at a young age. Our findings will provide important insights regarding prevention, risk stratification, treatment, and outcomes of cardiovascular disease in this understudied population, as well as identify disparities which, if addressed, can lead to further improvement in patient outcomes.     

Reproductive and Contraceptive Counseling Received by Adult Women with Congenital Heart Disease: A Risk‐based Analysis

Background/Objective. Our aim was to study the prevalence of counseling received by adult women with congenital heart disease to determine from whom they received such counseling and to describe their contraceptive and reproductive knowledge. Methods/Design. Using a cross‐sectional survey, information was collected from 83 women, ≥19 years of age with congenital heart disease from a group of 404 women followed in our adult congenital heart disease clinic. Women were stratified into combined hormonal contraceptive and pregnancy World Health Organization risk classes 1–4 based on cardiac lesion. Results. We hypothesized that >50% of women had not received both contraceptive and reproductive counseling that addressed their heart condition; indeed, 59% of women reported they had not received such counseling (P = .05). Women who had received heart‐specific contraceptive counseling were in higher risk combined hormonal contraceptive World Health Organization classes (P = .02). Similarly, women who reported receiving counseling regarding risks of pregnancy were also in higher pregnancy World Health Organization risk classes (P = .002). Fifty‐two of 77 women (63%) did not know if there was a contraindicated contraceptive method given their underlying heart condition; 16 of these 52 women (31%) were combined hormonal contraceptive class 3 or class 4. Conclusions. This adult congenital heart disease survey study demonstrates an opportunity to improve individualized contraceptive and reproductive counseling with a goal toward minimizing each patient's risk of potentially avoidable adverse events. A stronger collaboration among health care professionals is needed to increase the prevalence of heart‐specific counseling and to increase the quality of counseling these women are receiving.     

Association between transthoracic impedance and electrical cardioversion success with biphasic defibrillators: An analysis of 1055 shocks for atrial fibrillation and flutter

Background

The relevance of transthoracic impedance (TTI) to electrical cardioversion (ECV) success for atrial tachyarrhythmias when using biphasic waveform defibrillators is unknown.

Hypothesis

TTI is predictive of ECV success with contemporary defibrillators.

Methods

De‐identified data stored in biphasic defibrillator memory cards from ECV attempts for atrial fibrillation (AF) or atrial flutter (AFL) over a 2‐year period at our center were evaluated. ECV success, defined as arrhythmia termination and ≥ 1 sinus beat, was adjudicated by 2 blinded cardiac electrophysiologists. The association between TTI and ECV success was assessed via Cochrane‐Armitage trend and Spearman rank correlation tests, as well as simple and multivariable logistic regression. The influence of TTI on the number of shocks and on cumulative energy delivered per patient was also examined.

Results

703 patients (593 with AF, 110 with AFL) receiving 1055 shocks were included. Last shock success was achieved in 88.0% and 98.2% of patients with AF and AFL, respectively. In patients with AF, TTI was positively associated with last shock failure (P_trend =0.019), the need for multiple shocks (P_trend <0.001), and cumulative energy delivered (ρ = 0.348; P < 0.001). After adjusting for first shock energy, 10‐Ω increments in TTI were associated with odds ratios of 1.36 (95% CI: 1.24–1.49) and 1.22 (95% CI: 1.09–1.37) for first and last shock failure, respectively (P < 0.001 for both).

Conclusions

Although contemporary defibrillators are designed to compensate for TTI, this variable continues to be associated with ECV failure in patients with AF. Strategies to lower TTI during ECV for AF may improve procedural success.     

Appropriateness vs value: Echocardiography in primary care

Background

Despite efforts targeting the growth of healthcare spending within the United States, the current increase in expenditures remains a widespread systemic issue. The overuse of healthcare testing has previously been identified as a modifiable contributing factor. One such test, echocardiography, has seen a continuous increase in its rate of use. This test is frequently ordered by primary‐care physicians.

Hypothesis

In the setting of a low likelihood of disease, echocardiography does not substantially change cardiac therapy, even if appropriately ordered.

Methods

We randomly identified 500 patients who received an echocardiogram ordered by a primary‐care physician between January 1, 2014, and December 31, 2014. Of these, 239 patient charts were reviewed and the following extracted: primary indication for the test, echocardiogram results, and changes in patient medical management. In addition, appropriateness of the test was assessed using the appropriate use criteria guidelines for echocardiography.

Results

Nearly 97% of the studies within the ambulatory primary‐care setting were appropriately ordered according to the appropriate use criteria. Among the 239 patients studied, only 52 had abnormalities and only 6 (2.5%) experienced a change in management that corresponded with the initial suspected diagnosis and echocardiographic findings.

Conclusions

To ensure the greatest value and optimize use of diagnostic testing, it may be necessary to develop a more comprehensive set of guidelines to assist clinicians to readily identify patient populations at low, moderate, and high risk for the presence of disease and provide educational interventions, including feedback regarding individual ordering behaviors.

     

Harnessing mHealth technologies to increase physical activity and prevent cardiovascular disease

Research into prevention of cardiovascular disease has increasingly focused on mobile health (mHealth) technologies and their efficacy in helping individuals adhere to heart‐healthy recommendations, including daily physical activity levels. By including the use of mHealth technologies in the discussion of physical activity recommendations, clinicians empower patients to play an active daily role in modifying their cardiovascular risk‐factor profile. In this review, we critically evaluate the mHealth and physical activity literature to determine how these tools may lower cardiovascular risk while providing real‐time tracking, feedback, and motivation on physical activity levels. We analyze the various domains—including user knowledge, social support, behavioral change theory, and self‐motivation—that potentially influence the effectiveness of smartphone applications to impact individual physical activity levels. In doing so, we hope to provide a thorough overview of the mHealth landscape, in addition to highlighting many of the administrative, reimbursement, and patient‐privacy challenges of using these technologies in patient care. Finally, we propose a behavioral change model and checklist for clinicians to assist patients in utilizing mHealth technology to best achieve meaningful changes in daily physical activity levels.     

白藜芦醇保护缺血再灌注大鼠心肌作用与miR-21的相关性

目的 观察白藜芦醇预处理后大鼠心肌微小RNA(miRNA)的表达变化,分析白藜芦醇介导的心肌保护作用与miR-21之间有否关系.方法 通过miRNA芯片微阵列方法和qRT-PCR检测并验证白藜芦醇灌胃预处理后的大鼠心肌miRNA表达谱；建立大鼠心肌缺血再灌注损伤模型,检测各组心肌梗死面积、心肌细胞凋亡率以及miR-21的表达水平.结果 白藜芦醇预处理后,大鼠心肌的miR-21表达水平约为对照组的2.5倍;miR-21阻逼剂对白藜芦醇预处理引起的miR-21高表达产生了明显的抑制作用；过表达的miR-21显著降低了心肌细胞凋亡率,心肌组织梗死面积明显缩小.结论 白藜芦醇可以调控心肌多种miRNA的表达水平,通过促进miR-21的表达,白藜芦醇能够抑制心肌细胞的凋亡,从而减轻缺血再灌注对心肌的损伤.     

The design and rationale of SAVE BC: The Study to Avoid CardioVascular Events in British Columbia

Atherosclerotic cardiovascular disease (ASCVD) is highly heritable, particularly when it occurs at a young age. The screening of individuals with premature ASCVD, although often recommended, is not routinely performed. Strategies to address this gap in care are essential. We designed the Study to Avoid CardioVascular Events in British Columbia (SAVE BC) as a prospective, observational study of individuals with a new diagnosis of very premature ASCVD (defined as age ≤ 50 years in males and age ≤ 55 years in females) and their first‐degree relatives (FDRs) and spouses. FDRs and spouses will undergo screening for cardiovascular (CV) risk factors and subclinical ASCVD using a structured screening algorithm. All subjects will be followed longitudinally for ≥10 years. The overall goal of SAVE BC is to evaluate the yield of a structured screening program for identifying individuals at risk of premature ASCVD. The primary objectives of SAVE BC are to identify and follow index cases with very premature ASCVD and their FDRs and to determine the diagnostic yield of a structured screening program for these individuals. We will collect data on CV risk factors, medication use, CV events, and healthcare costs in these individuals. SAVE BC will provide insight regarding approaches to identify individuals at risk for premature ASCVD with implications for prevention and treatment in this population.     

Liver Disease in the Patient with Fontan Circulation

The Fontan procedure has undergone many modifications since first being performed on a patient with tricuspid valve atresia in 1968. It is now the procedure of choice for individuals born with single‐ventricle physiology or for those in whom a biventricular repair is not feasible. Forty years of experience with the Fontan procedure have gradually revealed the shortfalls of such a circulatory arrangement. Sequelae related to the underlying congenital anomaly or to the altered physiology of passive, nonpulsatile flow through the pulmonary arterial bed can result in failure of the Fontan circulation over time. Liver abnormalities including abnormalities in the clotting cascade have been well documented in Fontan patients. The clinical significance of these findings, however, has remained poorly understood. As Fontan survivors have increased in age and number, we have begun to better recognize subclinical hepatic dysfunction and the contribution of liver disease to adverse outcomes in this population. The purpose of this review is to summarize the existing data pertaining to liver disease in the Fontan population and to identify some questions that have yet to be answered.     

Extracardiac Complications in Adults with Congenital Heart Disease

With the increasing number of adults living with repaired, or unrepaired, congenital heart disease, there is a growing incidence of extracardiac comorbidities. These comorbidities can affect various organ systems in complex ways, and may have a significant impact on a patient's quality of life and survival. Many of these potential complications may go undiagnosed until there is already a significant bearing on the patient's life. Therefore, it is important for physicians who care for the adult congenital patient to be mindful of these potential extracardiac complications, and actively assess for these complications in their adult congenital practice. Continued research to identify modifiable risk factors is needed so that both preventative and therapeutic management options for these extracardiac complications may be developed.