Обзор американских кардиологических журналов за неделю (ссылки)

[Chevychelov]

Title: DNA Testing for Hypertrophic Cardiomyopathy: A Cost-Effectiveness Model
Topic: General Cardiology
Date Posted: 3/29/2010
Author(s): Wordsworth S, Leal J, Blair E, et al.
Citation: Eur Heart J 2010; Mar 18:[Epub ahead of print].
Clinical Trial: No
Study Question: What is the most cost-effective way to screen family members for hypertrophic cardiomyopathy (HCM)?
Methods: This was an economic decision model comparing cascade screening by genetic, as opposed to clinical methods.
Results: The incremental cost per life-year saved was 14,397 euros for the cascade genetic compared with the cascade clinical approach. The costs for cascade molecular genetic testing were slightly higher than clinical testing in the short-term, but this was largely because the genetic approach is more effective and identifies more individuals at risk.
Conclusions: The authors concluded that the use of molecular genetic information in the diagnosis and management of HCM is a cost-effective approach to the primary prevention of sudden cardiac death (SCD) in these patients.
Perspective: The role of genetic screening in the management of patients with HCM is controversial. The cost of the testing, uncertainty surrounding the causality of some mutations identified, false negatives, and the practical impact on patient management are a few concerns. In this simulated analysis, the authors demonstrate the potential utility of a genetic screening approach for first degree relatives of an HCM proband. Although many assumptions are made, more patients at risk for sudden death could be identified with genetic screening, which would lead to a higher rate of implantable cardioverter defibrillator implants, and presumably reduced SCD. The argument for screening will become even stronger if therapies are identified that prevent or modify HCM development in mutation carriers. Daniel T. Eitzman, M.D., F.A.C.C.

[Chevychelov]

Title: Long-Term Effectiveness and Safety of Sirolimus Stent Implantation for Coronary In-Stent Restenosis: Results of the TRUE (Tuscany Registry of Sirolimus for Unselected In-Stent Restenosis) Registry at 4 Years
Topic: Interventional Cardiology
Date Posted: 3/30/2010
Author(s): Liistro F, Fineschi M, Grotti S, et al.
Citation: J Am Coll Cardiol 2010;55:613-616.
Clinical Trial: No
Related Resources
JACC Article: Long-Term Effectiveness and Safety of Sirolimus Stent Implantation for Coronary In-Stent Restenosis: Results of the TRUE (Tuscany Registry of Sirolimus for Unselected In-Stent Restenosis) Registry at 4 Years

Study Question: What is the long-term outcome of patients treated with a sirolimus-eluting stent (SES) for coronary in-stent restenosis?
Methods: The authors reported the 4-year results of the TRUE registry. This registry enrolled 244 patients undergoing SES implantation for bare-metal coronary stent restenosis at two Italian hospitals.
Results: The incidence of target lesion revascularization (TLR) at 9 months was 5%. At 4 years, all-cause mortality was 9.8% and cardiac mortality was 4.5%. Nonfatal myocardial infarction occurred in 3.2% and TLR in 11.1%. The cumulative event-free survival was 80%. Definite stent thrombosis occurred in five (2%) patients and possible stent thrombosis in another two (0.8%). Independent predictors of poor outcome were diabetes, renal dysfunction, and low ejection fraction.
Conclusions: SES for treatment of bare-metal stent restenosis is associated with reasonable long-term safety and efficacy.
Perspective: The incidence of clinically relevant bare-metal stent restenosis has dramatically declined due to wider use of drug-eluting stents. Drug-eluting stents have emerged as the dominant mode of therapy for bare-metal stent restenosis, although there have been concerns that this may be associated with a higher incidence of late stent thrombosis. This study adds to a growing evidence base supporting use of SES for this indication (Alfonso F, et al., J Am Coll Cardiol 2008;52:1621-7.). Further studies are warranted to confirm if other drug-eluting stents also provide similar safety and efficacy compared with SES. Hitinder S. Gurm, M.B.B.S., F.A.C.C.

Title: Efficacy of High-Dose Atorvastatin Loading Before Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction: The STATIN STEMI Trial
Topic: Interventional Cardiology
Date Posted: 3/30/2010
Author(s): Kim JS, Kim J, Choi D, et al., on behalf of the STATIN STEMI Investigators.
Citation: JACC Cardiovasc Interv 2010;3:332-9.
Clinical Trial: yes
Related Resources
JACC Cardiovasc Interv Article: Efficacy of High-Dose Atorvastatin Loading Before Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction: The STATIN STEMI Trial
Trial: Efficacy of High-Dose Atorvastatin Loading Before Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction (STATIN STEMI)

Study Question: What is the benefit of preprocedural high-dose statins in patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI)?
Methods: The authors randomized 171 patients with STEMI to 80 mg atorvastatin (n = 86) or 10 mg atorvastatin (n = 85) arms for pretreatment before PCI. After PCI, both groups were treated with atorvastatin (10 mg). The primary endpoint was 30-day incidence of major adverse cardiac events (MACE) including death, nonfatal MI, and target vessel revascularization. Secondary endpoints included corrected Thrombolysis in Myocardial Infarction (TIMI) frame count, myocardial blush grade, and ST-segment resolution at 90 minutes after PCI.
Results: There was no difference in the primary endpoint, and MACE occurred in 5.9% versus 10.6% of patients in the 80 mg and 10 mg atorvastatin arms, respectively (p = 0.26). Corrected TIMI frame count was lower in the 80 mg atorvastatin arm (26.9 vs. 34.1, p = 0.01), and myocardial blush grade (2.2 vs. 1.9, p = 0.02) and ST-segment resolution (61.8 % vs. 50.6 %, p = 0.01) were better in the 80 mg atorvastatin arm.
Conclusions: High-dose atorvastatin pretreatment before PCI did not reduce MACE compared with low-dose atorvastatin, but was associated with an improvement in markers of myocardial perfusion after primary PCI.
Perspective: High-dose statins reduce reperfusion injury in animal models, and observational data suggest better outcome in patients with STEMI who are on chronic statin therapy. This trial failed to meet its primary endpoint, but it is unlikely that a reduction in hard events could be demonstrated in such a small trial. The improvement in markers of myocardial perfusion is encouraging, and further trials are needed to confirm these findings. Hitinder S. Gurm, M.B.B.S., F.A.C.C.

[Chevychelov]

Title: Nationwide Public-Access Defibrillation in Japan
Topic: Arrhythmias
Date Posted: 3/30/2010
Author(s): Kitamura T, Iwami T, Kawamura T, et al., on behalf of the Implementation Working Group for the All-Japan Utstein Registry of the Fire and Disaster Management Agency.
Citation: N Engl J Med 2010;362:994-1004.
Clinical Trial: No
Study Question: Do automatic external defibrillators (AEDs) improve survival in patients with out-of-hospital cardiac arrest (OHCA)?
Methods: The subjects of this study were 12,631 adults (mean age 64 years) with OHCA who were entered into a nationwide cardiac arrest registry in 2005-2007. During these 3 years, the number of public-access AEDs in Japan increased from 9,906 to 88,265. The 1° endpoint was survival at 1 month with minimal neurological impairment.
Results: The annual prevalence of bystander-initiated cardiopulmonary resuscitation (CPR) increased from 43.3% to 53.6% between 2005 and 2007, and the proportion of patients who received a shock from an AED increased from 1.2% to 6.2%. Survival at 1 month increased significantly from 10.6% in 2005 to 19.2% in 2007. Independent predictors of survival at 1 month included use of an AED (odds ratio [OR], 1.21) and time to first shock (OR, 0.91 per 1-minute increase).
Conclusions: An increase in public-access AEDs in Japan was associated with earlier defibrillation and an increase in survival at 1 month, with minimal neurological impairment in patients with OHCA.
Perspective: This is the first study to examine the potential impact of AEDs on outcomes after OHCA on a nationwide basis. Although the results are consistent with AEDs contributing to improved survival after OHCA, it is likely that other factors such as public education and an increase in bystander-initiated CPR also contributed. Fred Morady, M.D., F.A.C.C.

Title: Disparate Evolution of Right and Left Atrial Rate During Ablation of Long-Lasting Persistent Atrial Fibrillation
Topic: Arrhythmias
Date Posted: 3/30/2010
Author(s): Hocini M, Nault I, Wright M, et al.
Citation: J Am Coll Cardiol 2010;55:1007-1016.
Clinical Trial: No
Related Resources
JACC Article: Disparate Evolution of Right and Left Atrial Rate During Ablation of Long-Lasting Persistent Atrial Fibrillation

Study Question: How are drivers in the right atrium (RA) recognized during radiofrequency catheter ablation (RFCA) of persistent atrial fibrillation (PsAF) in the left atrium (LA)?
Methods: RFCA in the LA was performed in 148 patients (mean age 58 years) with PsAF (mean duration 25 months). The AF cycle length (CL) in the LA appendage (LAA) and RA appendage (RAA) was monitored during RFCA. The endpoint of RFCA was termination of AF. RA ablation was performed if there was an RAA-LAA frequency gradient after RFCA in the LA.
Results: Sinus rhythm was restored by RFCA in 86% of patients. In 70% of patients, there was a left-right CL gradient and a parallel increase in LAA and RAA CLs during RFCA in the LA preceding AF termination. In 30% of patients, AF was not terminated by LA RFCA; in these patients, there was a right-left CL gradient and the RAA CL did not increase in parallel with the LAA CL. RFCA in the RA terminated AF in 55% of this group. Independent predictors of the need for RA RFCA included LAA CL ≤165 ms after LA RFCA and RAA CL ≤160 ms after LA RFCA. After a mean of 1.5 procedures/patient, 87% of patients were in sinus rhythm at a mean of 22 months of follow-up.
Conclusions: The failure of RAA CL to increase in parallel with the LAA CL during LA RFCA of PsAF identifies patients who require RA RFCA for termination of AF.
Perspective: The results suggest that the RA contains drivers of AF in approximately 20% of patients with PsAF. Fred Morady, M.D., F.A.C.C.

[Chevychelov]

Title: Usefulness of Exercise-Stress Echocardiography for Risk Stratification of True Asymptomatic Patients With Aortic Valve Stenosis
Topic: Noninvasive Cardiology
Date Posted: 3/29/2010
Author(s): Marйchaux S, Hachicha Z, Bellouin A, et al.
Citation: Eur Heart J 2010;Mar 21:[Epub ahead of print].
Clinical Trial: No
Study Question: Among asymptomatic patients with aortic stenosis (AS) with a normal response to exercise testing, does exercise stress echocardiography add incremental prognostic value to resting echocardiography?
Methods: A retrospective analysis was performed using data from 186 patients with at least moderate AS (valve area <1.5 cm2, indexed valve area <0.9 cm2/m2) and preserved left ventricular (LV) ejection fraction (≥50%) who underwent exercise stress echocardiography at one of four hospitals. Outcomes were cardiac death or aortic valve replacement (AVR) motivated by development of symptoms.
Results: There was an abnormal response to exercise in 51 (27%). Among the remaining 135 patients with a normal exercise test (53% with severe AS) at a mean follow-up of 20 ± 14 (median 19) months, a cardiac event occurred in 67 (AVR motivated by symptoms in 58, severe symptoms without AVR in four, symptoms awaiting AVR in one, cardiovascular death in three, and cardiac arrest followed by resuscitation and AVR in one). The variables independently associated with events were age ≥65 years (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.15-3.47; p = 0.01), diabetes (HR, 3.20; 95% CI, 1.33-6.87; p = 0.01), LV hypertrophy (HR, 1.96; 95% CI, 1.17-3.27; p = 0.01), resting mean gradient >35 mm Hg (HR, 3.60; 95% CI, 2.11-6.37; p < 0.0001), and exercise-induced increase in mean gradient >20 mm Hg (HR, 3.83; 95% CI, 2.16-6.67; p < 0.0001).
Conclusions: Exercise-induced increase in transvalvular gradient may be helpful to improve risk stratification in asymptomatic patients with AS and a normal exercise response. Exercise stress echocardiography may provide additional prognostic information over that obtained from standard exercise testing and resting echocardiography.
Perspective: Asymptomatic patients with severe AS traditionally are thought to have a low risk of adverse cardiac events, justifying a conservative philosophy of waiting for symptoms before considering AVR. However, it has become clear that not all asymptomatic patients are at the same low risk. Exercise testing (screening for the development of symptoms, hypotension, or complex ventricular arrhythmias) appears to offer incremental prognostic value. The present study suggests that an increase in AV gradient during exercise also might add incremental prognostic information. Notably, this study included roughly equal numbers of patients with moderate AS and with severe AS, and separate multivariate analyses revealed that an exercise-induced increase in gradient was strongly associated with risk in both categories. In addition, the authors observed that the increase in gradient during exercise did not correlate with resting gradient or any other resting echocardiographic variable. These findings serve to underscore some of the difficulties in determining the true hemodynamic impact of stenotic valve lesions, and the associated clinical challenges in treating patients with valvular heart disease. David S. Bach, M.D., F.A.C.C.

[Chevychelov]

Title: Physical Activity and Weight Gain Prevention
Topic: Prevention/Vascular
Date Posted: 3/31/2010
Author(s): Lee IM, Djousse L, Sesso HD, Wang L, Buring JE.
Citation: JAMA 2010;303:1173-1179.
Clinical Trial: No
Study Question: In 2008, federal guidelines recommended at least 150 minutes per week (7.5 metabolic equivalent [MET] hours per week) of moderate-intensity activity for “substantial health benefits.” What is the association of physical activity with long-term weight changes among women consuming a usual diet?
Methods: This prospective cohort study involved 34,079 healthy women participating in the Women’s Health Study from 1992-2007. At baseline and years 3, 6, 8, 10, 12, and 13, women reported their physical activity and body weight. Women were classified as expending <7.5, 7.5 to <21, and ≥21 MET hours per week of activity at each time. Repeated-measures regression prospectively examined physical activity and weight change over intervals averaging 3 years.
Results: At baseline, mean age was 54.2 years; about 50% of the women expended <7.5 MET hours per week; mean body mass index (BMI) was 26 kg/m2; 94% were white; and 40% were on hormone therapy. Mean (standard deviation) energy intake was similar between groups (~1725 [542] kcal/d). Women gained a mean of 2.6 kg throughout the study. A multivariate analysis comparing women expending ≥21 MET hours per week with those expending from 7.5 to <21 MET hours per week showed that the latter group gained a mean of 0.11 (0.04) kg (p = 0.003) over a mean interval of 3 years, and those expending <7.5 MET hours per week gained 0.12 (0.04) kg (p = 0.002). There was a significant interaction with BMI; an inverse dose-response relation between activity levels and weight gain among women with a BMI of <25 kg/m2 (p for trend < 0.001), but no relation among women with a BMI from 25-29.9 (p for trend = 0.56) or with a BMI of 30.0 kg/m2 or higher (p for trend = 0.50). A total of 4,540 women (13.3%) with a BMI lower than 25 kg/m2 at study start successfully maintained their weight by gaining <2.3 kg throughout. Their mean activity level over the study was 21.5 MET hours per week (~60 minutes a day of moderate-intensity activity).
Conclusions: Among women consuming a usual diet, physical activity was associated with less weight gain only among women whose BMI was lower than 25 kg/m2. Women successful in maintaining normal weight and gaining fewer than 2.3 kg over 13 years averaged approximately 60 minutes a day of moderate-intensity activity throughout the study.
Perspective: How many women 52 years of age would exercise 60 minutes a day in order to not gain more than 5 pounds over 13 years? One per 1,000? The authors had two posits, neither of which makes sense: 1) once overweight, it may be too late because physical activity is not associated with less weight gain; 2) sustaining high levels of physical activity (~60 minutes a day) is needed to successfully maintain normal BMI and prevent weight gain. While MET hours per week of activity is a reasonable way to estimate kcal/day of energy expenditure, over 95% of kcal of energy is expended at rest or during sleep. Weight gain in middle-aged men and women is highly related to increasing energy intake, which was not measured in these women. Adding the equivalent of one slice of bread per day (100 kcal) could on average result in ~10 pounds of weight gain in 1 year. The impact of supersizing and fast foods cannot be overcome by exercise. Melvyn Rubenfire, M.D., F.A.C.C.

Title: Mipomersen, an Apolipoprotein B Synthesis Inhibitor, for Lowering of LDL Cholesterol Concentrations in Patients With Homozygous Familial Hypercholesterolaemia: A Randomised, Double-Blind, Placebo-Controlled Trial
Topic: Prevention/Vascular
Date Posted: 3/31/2010
Author(s): Raal FJ, Santos RD, Blom DJ, et al.
Citation: Lancet 2010;375:998-1006.
Clinical Trial: yes
Study Question: Homozygous familial hypercholesterolemia (HoFH) is a rare genetic disorder in which both low-density lipoprotein (LDL)-receptor alleles are defective, resulting in very high concentrations of LDL cholesterol in plasma and premature coronary artery disease. Is mipomersen, an anti-sense inhibitor of apolipoprotein (apo) B synthesis, as effective and safe as an adjunctive agent to lower LDL cholesterol concentrations in patients with HoFH?
Methods: A randomized, double-blind, placebo-controlled, phase 3 study was undertaken in nine lipid clinics. Patients ages 12 years and older with clinical diagnosis or genetic confirmation of HoFH, who were already receiving the maximum tolerated dose of a lipid-lowering drug, were randomly assigned to mipomersen 200 mg subcutaneously or placebo weekly for 26 weeks. The primary endpoint was percentage change in LDL cholesterol concentration from baseline with analysis by intention to treat.
Results: Mean (standard deviation) age was 31 (12) years and seven were younger than 18 years old; 57% were women; 57% were true HoFH and 26% compound heterozygotes; 74% were on maximal statin dose + ezetimibe. Mean values for lipids were similar between groups: LDL cholesterol 425 mg/dl and apo B 270 mg/dl. Thirty-four patients were assigned to mipomersen and 17 to placebo. Forty-five patients completed the 26-week treatment period (28 mipomersen, 17 placebo). The mean percentage change in LDL-C was significantly greater with mipomersen (-24.7%, 95% confidence interval, -31.6 to -17.7) than with placebo (-3.3%, -12.1 to 5.5; p = 0.0003). The treatment effect of mipomersen on LDL cholesterol varied from -82% to +2% and with placebo varied from -30% to +40%. The most common adverse events were injection-site reactions (26 [76%] patients in the mipomersen group vs. four [24%] in the placebo group). Four (12%) patients in the mipomersen group but none in the placebo group had increases in concentrations of alanine aminotransferase of three times or more the upper limit of normal.
Conclusions: Inhibition of apo B synthesis by mipomersen represents a novel, effective therapy to reduce LDL cholesterol concentrations in patients with homozygous FH who are already receiving lipid-lowering drugs, including high-dose statins.
Perspective: The potential use of anti-sense oligonucleotides that inhibit protein synthesis by binding to mRNA is quite appealing for many conditions, particularly anti-apo B synthesis in FH where statins are limited in their ability to up-regulate LDL receptor activity. The 25% reduction in LDL cholesterol with mipomersen seems modest, but represents about a 100 mg/dl reduction. If mipomersen is safe, it has great potential in those refractory to statins, but more importantly those who are statin intolerant. Melvyn Rubenfire, M.D., F.A.C.C.

[Chevychelov]

Title: Loss of Pace Capture on the Ablation Line: A New Marker for Complete Radiofrequency Lesions to Achieve Pulmonary Vein Isolation
Topic: Arrhythmias
Date Posted: 4/2/2010
Author(s): Steven D, Reddy VY, Inada K, et al.
Citation: Heart Rhythm 2010;7:323-330.
Clinical Trial: No
Study Question: How useful is pacing on antral ablation lines for identifying target sites for pulmonary vein (PV) isolation?
Methods: Antral radiofrequency (RF) catheter ablation was performed in 30 patients (mean age 57 years) with paroxysmal atrial fibrillation. Ablation sites were tagged on an electroanatomical mapping system. A ring catheter was positioned in the PVs, but the operators were blinded to the electrogram recordings during ablation. Pacing was performed at 10 mA (2 ms pulse width) along the antral ablation line, and additional ablation was performed at sites of atrial capture until loss of capture was achieved along the entire ablation line. Bidirectional PV conduction block then was assessed with the ring catheter and by pacing within the PVs.
Results: Loss of capture along the entire antral ablation line was achieved for all pairs of ipsilateral PVs. Loss of pacing capture was associated with complete PV isolation by conventional criteria for 95% of ipsilateral PV pairs. Retrospective analysis of ring catheter recordings demonstrated that loss of capture along the antral ablation line required a mean of 10 additional RF applications beyond the point at which PV entrance block was achieved based on ring catheter electrograms.
Conclusions: Loss of pacing capture along antral ablation lines is a reliable indicator of PV isolation.
Perspective: The new technique described in this study has two advantages over existing endpoints for antral ablation to isolate the PVs: 1) only one catheter is required in the left atrium, and 2) loss of capture may be a more reliable indicator of complete conduction block than loss of PV potentials on a ring catheter. Fred Morady, M.D., F.A.C.C.

Title: Carotid Sinus Syndrome, Should We Pace? A Multicentre, Randomised Control Trial (Safepace 2)
Topic: Arrhythmias
Date Posted: 4/2/2010
Author(s): Ryan DJ, Nick S, Colette SM, Roseanne K.
Citation: Heart 2010;96:347-351.
Clinical Trial: yes
Study Question: Does pacing reduce falls in elderly patients with cardioinhibitory carotid sinus hypersensitivity (CICSH)?
Methods: The subjects of this study were 141 patients over the age of 65 years (mean age 78 years) who had a mean of approximately five falls in the prior year and ≥3 seconds of asystole during carotid sinus massage. They were randomly assigned to receive an implantable loop recorder (ILR, n = 71) or a dual-chamber pacemaker (n = 70). The 1° endpoint was the number of falls during 24 months of follow-up.
Results: The risk of falling during follow-up decreased by approximately 75% in both study groups. There was no significant difference in the number of falls during follow-up between the ILR and pacemaker groups. No episodes of asystole were recorded by the ILRs.
Conclusions: Pacing is of questionable value in elderly patients with falls and CICSH.
Perspective: The results dramatically demonstrate the nonspecific nature of a positive response to carotid sinus massage and also the placebo value of device implantation, even when the device is purely diagnostic. A prior single-center study (Safepace 1) reported that pacing did reduce the number of falling episodes in elderly patients with CICSH, but based on the results of this multicenter study, an ILR would seem more appropriate. Pacemaker implantation should be reserved for patients demonstrated to have symptomatic bradycardia or asystole. Fred Morady, M.D., F.A.C.C.

[Chevychelov]

Title: The Development of Heart Failure in Patients With Diabetes Mellitus and Pre-Clinical Diastolic Dysfunction: A Population-Based Study
Topic: Heart Failure/Transplant
Date Posted: 4/1/2010
Author(s): From AM, Scott CG, Chen HH.
Citation: J Am Coll Cardiol 2010;55:300-305.
Clinical Trial: No
Related Resources
JACC Article: The Development of Heart Failure in Patients with Diabetes Mellitus and Pre-Clinical Diastolic Dysfunction: A Population-Based Study

Study Question: What is the clinical outcome of diabetic patients with preclinical diastolic dysfunction (DD)?
Methods: Patients with diabetes mellitus (DM) who had evidence of DD, based on Doppler echocardiography [mitral valve inflow (E) to early annular velocity (e’); E/e’ >15], were identified from a database search. Data were collected retrospectively and tabulated for mortality, and development of congestive heart failure (CHF) and atrial fibrillation (AF). Patients with CHF predating the echocardiogram and those in whom CHF was diagnosed within 30 days of the echocardiogram were excluded from the analysis.
Results: A database search identified 12,014 subjects with DM, 2,770 of whom had Doppler assessment of DD. After excluding patients with valvular heart disease and a proximate diagnosis of CHF, 1,760 patients were included in the study, of whom 411 (23%) had E/e’ >15. Average follow-up was 2.9 ± 1.8 years. Patients with DD were older (67 ± 13 vs. 58 ± 14 years) and more often female (61% vs. 48%). Patients with DD had a higher prevalence of hypertension (91% vs. 84%), coronary artery disease (43% vs. 34%), larger left atrial volume (73 ± 25 vs. 60 ± 23 ml), and higher left ventricular mass index (107 ± 29 vs. 104 ± 23 g/m2) (all comparisons p < 0.001). For the population, E/e’ was 13 ± 6, and was 21 ± 6 in those with DD and 11 ± 3 in those without (p < 0.001). The probability of new CHF for patients with DD was 13.1% at 1 year and 36.9% at 5 years compared to 5.2% and 16.8% for those without DD (p < 0.001). The probability of death for diabetics with DD was 6.9% at 1 year and 30.8% at 5 years compared to 3.1% and 12.1% for those without DD (p < 0.001). At baseline, 1,450 patients were without a previous diagnosis of AF. AF subsequently developed in 6.8% of patients with DD at 1 year and 18.7% at 5 years compared to 2.1% and 8.8% for those without DD.
Conclusions: DD is present in 23% of patients with DM who did not have a proximate history of CHF, and is associated with a higher subsequent rate of CHF, higher mortality, and higher likelihood of AF.
Perspective: Previous studies have documented DD in patients with diabetes. This retrospective study demonstrates an association of DD with subsequent development of CHF, mortality, and AF. Multivariable analysis suggested that DD is an independent predictor of outcomes after adjusting for age, gender, hypertension, coronary disease, and other echocardiographic parameters, with a hazard ratio of 1.61. There are a number of limitations to this study including its retrospective nature and absence of data regarding the indication for the initial echocardiogram. Additionally, this was an overwhelmingly Caucasian population, and results may not be generalizable to the nonwhite population. Within the limits of retrospective study, patients with a previous diagnosis of CHF were excluded from the analysis; however, it is unclear what the indication of the echocardiogram was in a large number of presumably asymptomatic patients with diabetes. Additionally, the average E/e’ of 21 in the patients with DD suggests advanced DD with a high likelihood of markedly elevated left atrial pressures. The degree to which patients with a statistically high likelihood of markedly elevated left atrial pressures (>18 mm Hg) were truly asymptomatic requires further elucidation. This study would suggest that there is a substantial percentage of presumably asymptomatic patients (23%) with diabetes who have occult (or possibly impending) CHF. Whether aggressive approaches to hypertension and diabetes control would mitigate the development of subsequent AF, heart failure, and death would need to be prospectively evaluated. William F. Armstrong, M.D., F.A.C.C

Title: Risk and Fate of Cerebral Embolism After Transfemoral Aortic Valve Implantation: A Prospective Pilot Study With Diffusion-Weighted Magnetic Resonance Imaging
Topic: Cardiovascular Surgery
Date Posted: 4/1/2010
Author(s): Ghanem A, Mьller A, Nдhle CP, et al.
Citation: J Am Coll Cardiol 2010;55:1427-1432.
Clinical Trial: No
Related Resources
JACC Article: Risk and Fate of Cerebral Embolism After Transfemoral Aortic Valve Implantation: A Prospective Pilot Study With Diffusion-Weighted Magnetic Resonance Imaging

Study Question: What are the implications of silent and clinically apparent cerebral embolic events and neurological impairment after transfemoral aortic valve implantation (TAVI)?
Methods: Cerebral diffusion-weighted magnetic resonance imaging (DW-MRI) was performed before, directly, and 3 months after TAVI with the current third-generation self-expanding CoreValve (Medtronic, Minneapolis, MN) prosthesis. At the timepoints of the serial MRI studies, focal neurological impairment was assessed according to the National Institutes of Health Stroke Scale (NIHSS), and serum concentration of neuron-specific enolase (NSE), a marker of the volume of brain tissue involved in an ischemic event, were determined. Association between frequency of embolic events and continuous variables was examined by Spearman's correlation.
Results: Thirty patients were enrolled; 22 completed the imaging protocol. Three patients (10%) had new neurological findings after TAVI, of whom only one (3.6%) had a permanent neurological impairment. Of the 22 TAVI patients with complete imaging data, 16 (72.7%) had 75 new cerebral lesions after TAVI presumed to be embolic. The NIHSS and NSE were not correlated with DW-MRI lesions.
Conclusions: The authors concluded that the incidence of clinically silent peri-interventional cerebral embolic lesions after TAVI is high.
Perspective: The current study suggests that the incidence of clinically silent peri-interventional cerebral embolic lesions after TAVI is high, but the incidence of persistent neurological impairment was quite low. The knowledge about silent TAVI-related cerebral embolism should highlight the importance of the careful management of peri-interventional anticoagulation in patients undergoing TAVI. Additional studies with longer-term clinical follow-up are indicated to understand the implications of the high rate of cerebral embolism with this procedure. Debabrata Mukherjee, M.D., F.A.C.C.

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Title: Identifying Patients at High Risk of a Cardiovascular Event in the Near Future: Current Status and Future Directions: Report of a National Heart, Lung, and Blood Institute Working Group
Topic: General Cardiology
Date Posted: 4/1/2010
Author(s): Eagle KA, Ginsburg GS, Musunuru K, et al.
Citation: Circulation 2010;121;1447-1454.
Clinical Trial: No
Perspective: Coronary artery disease is a complex process arising from the interplay of genetic variations, fluctuations in protein expression and activity, and environmental exposures. Thus, individuals with coronary artery disease may likely have differing manifestations of their disease despite having similar clinical phenotypes of atherosclerotic plaque and/or myocardial infarction. It is possible that future research on inflammation, endothelium, thrombosis, myocardium, environmental triggers, and psychosocial factors; imaging tests; and studies on genomics, proteomics, and gene expression will ultimately help unravel the complexity of coronary artery disease sufficiently to provide information on the risk of events for an individual patient. This in turn will help guide more precise and targeted therapies aimed at the particular individual. This working group recognized the need for comprehensive, integrative methods of analysis that will evaluate and assess the combined prognostic implications of these data to refine and fine-tune near-term risk assessment and ultimately guide optimal therapies for the individual patient. Debabrata Mukherjee, M.D., F.A.C.C.

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Title: Impact of Delay to Angioplasty in Patients With Acute Coronary Syndromes Undergoing Invasive Management: Analysis From the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) Trial
Topic: Interventional Cardiology
Date Posted: 3/29/2010 5:00:00 PM
Author(s): Sorajja P, Gersh BJ, Cox DA, et al.
Citation: J Am Coll Cardiol 2010;55:1416-1424.
Clinical Trial: No
Related Resources
JACC Article: Impact of Delay to Angioplasty in Patients With Acute Coronary Syndromes Undergoing Invasive Management: Analysis From the ACUITY Trial
Trial: Acute Catheterization and Urgent Intervention Triage Strategy Trial (ACUITY )

Study Question: What is the impact of delay to angioplasty in patients with non–ST-segment elevation acute coronary syndrome (NSTE-ACS)?
Methods: The authors assessed the impact of time to percutaneous coronary intervention (PCI) in patients enrolled in the ACUITY trials by categorizing them into those that underwent PCI <8 hours, 8-24 hours, and >24 hours after presentation.
Results: The study cohort was comprised of 7,749 patients who underwent PCI at a median of 19.5 hours after presentation. A total of 2,197 patients underwent PCI within 8 hours of presentation, 2,740 between 8-24 hours, and 2,812 underwent PCI >24 hours after presentation. PCI after >24 hours of presentation was associated with increased 30-day mortality (0.8%, 0.5%, and 1.7%), myocardial infarction (4.9%, 5.6%, and 8.0%), and composite of death, myocardial infarction, and unplanned revascularization (7.9%, 7.9%, and 10.4%). After adjusting for baseline differences, delay to PCI of >24 hours was a significant independent predictor of 30-day and 1-year mortality.
Conclusions: A delay from admission to PCI >24 hours in patients with NSTE-ACS was an independent predictor of early and late mortality and adverse ischemic outcomes.
Perspective: While an early invasive therapy is considered the preferred management strategy in patients with NSTE-ACS, how early is early enough is still debatable. Although this study suggests that the best outcome is seen in those who underwent PCI between 8-24 hours after admission, it is not clear if the difference in outcome was purely due to the delay to PCI or driven by factors that were responsible for the delay in PCI. The ABOARD study failed to detect a difference in outcome with immediate versus next day intervention (mean delay 21 hours), whereas the TIMACS trial suggested a benefit of early intervention (within 24 hours of presentation) in the highest risk patients. These data would suggest that it is probably best to time the intervention for the next working day in patients with NSTE-ACS. Hitinder S. Gurm, M.B.B.S., F.A.C.C.

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TAD Guidelines Address Catastrophic CV Disease
HF Patients Seem to Benefit from Clopidogrel
[Ссылки доступны только зарегистрированным пользователям ]

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Title: Acute Myocardial Infarction Hospitalization in the United States, 1979 to 2005
Topic: General Cardiology
Date Posted: 4/5/2010
Author(s): Fang J, Alderman MH, Keenan NL, Ayala C.
Citation: Am J Med 2010;123:259-266.
Clinical Trial: No
Study Question: What are the trends in acute myocardial infarction (AMI) hospitalization rates for 27 years, from 1979 to 2005?
Methods: The investigators determined hospitalization rates for AMI by age and gender using data from the National Hospital Discharge Survey and US civilian population from 1979 to 2005, aggregated by 3-year groupings. They also assessed comorbid, complications, cardiac procedure use, and in-hospital case-fatality rates.
Results: Age-adjusted hospitalization rate for AMI identified by primary International Classification of Diseases code was 215 per 100,000 people in 1979-1981 and increased to 342 in 1985-1987. Thereafter, the rate stabilized for the next decade and then declined slowly after 1996 to 242 in 2003-2005. Trends were similar for men and women, although rates for men were almost twice that of women. Hospitalization rates increased substantially with age and were the highest among those ages 85 years or more. Although median hospital stay decreased from 12 to 4 days, intensity of hospital care increased, including use of coronary angioplasty, coronary bypass, and thrombolytics therapy. During the period, reported comorbidity from diabetes and hypertension increased. AMI complicated by heart failure increased, and cardiogenic shock decreased. Altogether, the in-hospital case-fatality rate declined.
Conclusions: The authors concluded that during the past quarter century, hospitalization for AMI increased until the mid-1990s, but has declined since then.
Perspective: This analysis suggests that during the past quarter century, hospitalization for AMI has only begun to decline more recently. At the same time, there has been a trend toward more intensive acute care and vastly expanded use of invasive procedures. The changes in AMI observed can be attributed to multiple factors, including change in incidence rates and reduction in risk of death before hospitalization, changing diagnostic criteria of MI, hospital treatment, and data-collection methods. The use of more sensitive biomarkers has probably contributed significantly to the increased diagnosis of MI in recent years. It is reassuring that in-hospital case-fatality rates have declined steadily, but we need to continue to be vigilant about providing optimal secondary preventative therapies to patients presenting with an MI. Debabrata Mukherjee, M.D., F.A.C.C.

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Title: Assessment of Radiofrequency Ablation Lesions by CMR Imaging After Ablation of Idiopathic Ventricular Arrhythmias
Topic: Noninvasive Cardiology
Date Posted: 4/5/2010
Author(s): Ilg K, Baman TS, Gupta SK, et al.
Citation: JACC Cardiovasc Imaging 2010;3:278-285.
Clinical Trial: No
Related Resources
JACC Cardiovasc Imaging Article: Assessment of Radiofrequency Ablation Lesions by CMR Imaging After Ablation of Idiopathic Ventricular Arrhythmias

Study Question: How useful is cardiac magnetic resonance imaging (CMR) with delayed enhancement for assessing the lesions created by radiofrequency (RF) ablation of idiopathic ventricular tachycardia (VT) and premature ventricular complexes (PVCs)?
Methods: In a consecutive series of 35 patients (19 women, ages 48 ± 15 years, ejection fraction 0.56 ± 0.12) without structural heart disease who were referred for ablation of ventricular arrhythmias, CMR with delayed enhancement was performed before and after ablation. Ablation lesions were sought in the post-ablation CMR images. The endocardial area, depth, and volume of the lesions were measured. Lesion size was correlated with the type of ablation catheter used and the duration of RF energy delivered.
Results: In 25 of 35 patients (71%), ablation lesions were identified by delayed enhancement a mean of 22 ± 12 months after the initial ablation procedure. The mean lesion volume was 1.4 ± 1.4 cm3, with a mean endocardial area of 3.5 ± 3.0 cm2. The largest lesions (mean volume of 2.9 ± 2.1 cm3 with an endocardial area of 6.4 ± 3.4 cm2) were identified in patients in whom the arrhythmias originated in the papillary muscles. Ablation duration correlated with lesion size (r = 0.67, p < 0.001). There was no difference in lesion volume with irrigated versus nonirrigated ablation catheters (1.0 ± 0.73 vs. 2.0 ± 2.1 cm3, p = 0.09). Identification of ablation lesions in patients with a failed procedure identified the sites where ineffective RF energy lesions were created.
Conclusions: The authors concluded that RF ablation lesions can be detected long-term after an ablation procedure targeting ventricular arrhythmias in patients without previous infarction.
Perspective: This study suggests that ablation lesions that target idiopathic ventricular arrhythmias often result in scars that are apparent by CMR. A larger patient population is required to allow confirmation of the initial observations described in this study with regard to the lesion sizes created by different types of ablation catheters. In the future, real-time CMR guidance of VT ablation may provide the electrophysiologist with live information regarding the underlying scar substrate, and allow more precise treatment of lesions and optimal use of catheters. Such integration of CMR technology will also likely improve the safety and efficacy of VT ablation procedures. Debabrata Mukherjee, M.D., F.A.C.C.

Title: Heart Failure Symptom Assessment and Management: Can Caregivers Serve as Proxy?
Topic: Heart Failure/Transplant
Date Posted: 4/5/2010
Author(s): Quinn C, Dunbar SB, Higgins M.
Citation: J Cardiovasc Nurs 2010;25:142-148.
Clinical Trial: No
Study Question: What is the degree of congruence between heart failure (HF) patients and their primary caregivers on symptom assessment and self-care management behaviors?
Methods: Seventy HF patients (primarily between 40 and 85 years of age) receiving home health care and their designated caregivers (CGs) were studied. Caregivers were predominately female (76%) and spouses (43%). Congruence in symptom assessment and management between HF patients and their designated CGs was measured in this descriptive cross-sectional study using the Heart Failure Symptom Survey and Self-care of Heart Failure Index.
Results: The Spearman correlation coefficient and concordance correlation coefficient were used to assess the degree of congruence on symptom evaluation scores from the Heart Failure Symptom Survey. Strongest correlations were seen on ratings of the HF patients’ symptoms of extremity edema, difficulty concentrating, and dizziness. Lower congruence (Spearman correlation <0.40) was found on feeling depressed, shortness of breath at night, and shortness of breath when lying down. Scores on the Self-care of Heart Failure Index self-care management and self-care confidence scales were not significantly different within the HF dyads.
Conclusions: The CG appears to be a reasonable substitute for patient responses in a community setting, based on moderate levels of correlations on most HF symptoms in this study. Symptoms for which there were higher levels of congruence include extremity edema, difficulty concentrating, and dizziness. Shortness of breath at night or while lying down, worsening cough, and bloated abdomen are more difficult for the CG to recognize.
Perspective: This is the first study to specifically examine congruence in symptom assessment with HF/CG dyads. Further studies are needed to explore the CG’s recognition of subtle symptoms of HF and how this affects HF patient outcomes. CG symptom assessment must include the subtle signs of HF that may not be easily recognized by another. Enhanced patient/CG education in this regard may be helpful in future symptom assessment. Suzanne Hughes, MSN, RN

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Title: Using Care Bundles to Reduce In-Hospital Mortality: Quantitative Survey
Topic: General Cardiology
Date Posted: 4/6/2010
Author(s): Robb E, Jarman B, Suntharalingam G, Higgens C, Tennant R, Elcock K.
Citation: BMJ 2010;340:c1234.
Clinical Trial: No
Study Question: What is the effect of care bundles targeted to the diagnoses responsible for the largest number of deaths on hospital inpatient mortality?
Methods: Eight care bundles of treatments known to be effective in reducing in-hospital mortality were used in the intervention year; adjusted mortality (from hospital episode statistics) was compared to the preceding year for the 13 diagnoses targeted by the intervention care bundles, 43 nontargeted diagnoses, and overall mortality for the 56 hospital standardized mortality ratio (HSMR) diagnoses covering 80% of hospital deaths. The institute defined a care bundle as “a collection of processes needed to effectively and safely care for patients undergoing particular treatments with inherent risks. Several interventions are ‘bundled’ together and, when combined, significantly improve patient care outcomes.” Change in adjusted mortality in targeted and nontargeted diagnostic groups and HSMR during the intervention year compared with the preceding year were the key measures of improvement.
Results: The standardized mortality ratio (SMR) of the targeted diagnoses and the HSMR both showed significant reductions, and the nontargeted diagnoses showed a slight reduction. Cumulative sum charts showed significant reductions of SMRs in 11 of the 13 diagnoses targeted in the year of the quality improvements, compared with the preceding year. The HSMR of the trust fell from 89.6 in 2006-7 to 71.1 in 2007-8 to become the lowest among acute trusts in England. Two hundred fifty-five fewer deaths occurred in the trust (174 of these in the targeted diagnoses) in 2007-8 for the HSMR diagnoses than if the 2006-7 HSMR had been applicable. From 2006-7 to 2007-8, there was a 5.7% increase in admissions, 7.9% increase in expected deaths, and 14.5% decrease in actual deaths.
Conclusions: The authors concluded that implementing care bundles can lead to reductions in death rates in the clinical diagnostic areas targeted and in the overall hospital mortality rate.
Perspective: The current study reports the results of implementing care bundles (guidelines for effective and safe patient care) targeted on reducing mortality in several diagnostic areas with a high numbers of deaths. Significant reductions in targeted disease and overall mortality were noted with these efforts. Prior initiatives in other countries using standardized orders and care protocols have also led to reduced mortality. The methods described in this study, of determining the main causes of death in a hospital and then using methods of treatment (care bundles) developed from evidence of their effectiveness to reduce mortality in the targeted diagnostic areas, could be applied to hospitals globally with improved outcomes. Debabrata Mukherjee, M.D., F.A.C.C.

Title: Chocolate Consumption in Relation to Blood Pressure and Risk of Cardiovascular Disease in German Adults
Topic: Prevention/Vascular
Date Posted: 4/6/2010
Author(s): Buijsse B, Weikert C, Drogan D, Bergmann M, Boeing H.
Citation: Eur Heart J 2010;Mar 30:[Epub ahead of print].
Clinical Trial: No
Study Question: Does chocolate consumption decrease both blood pressure and incidence of cardiovascular disease (CVD)?
Methods: Data from the participants of the Postdam arm of the European Prospective Investigation into Cancer and Nutrition study were used for this analysis. Participants were from the general population of Postdam, Germany and its surroundings. Men and women took part in a baseline (1994-98) assessment, which included a food-frequency questionnaire, blood pressure measurement, anthropometric measures, sociodemographic factors, and lifestyle characteristics. Follow-up continued every 2-3 years (response rates ranged from 90-96%). Participants were excluded if a history of CVD was present at baseline. Additional exclusion criteria included use of antihypertensive medications (at baseline), missing information on blood pressure, diet, or the outcomes of interest (stroke and myocardial infarction [MI]). Cases of CVD (stroke and MI) were identified by self-report with verification through medical records.
Results: A total of 10,904 men (ages 40-65 years) and 16,644 women (ages 35-65 years) were included in the study. During the mean follow-up of 8 years, 166 cases of MI and 136 cases of stroke occurred. The top quartile of chocolate consumption included 8.1% of the cohort who consumed approximately 6 g/day more of chocolate compared to those in the bottom quartile. After controlling for age, sex, lifestyle factors, anthropometrics, diet, and prevalence of diabetes, chocolate consumption appeared protective for CVD (relative risk [RR], 0.61; 95% confidence interval [CI], 0.44-0.87). This relationship appeared stronger for stroke, with those in the top quartile for chocolate consumption having less risk (RR, 0.52; 95% CI, 0.30-0.89), as compared to those in the bottom quartile. For MI, the association was nonsignificant (RR, 0.73; 95% CI, 0.47-1.15). Mean systolic blood pressure was lower in the same group, 1.0 mm Hg (95% CI, -1.6 to -0.04 mm Hg) and mean diastolic was also lower, 0.9 mm Hg (95% CI, -1.13 to -0.5 mm Hg). Baseline blood pressure explained 12% of the lower risk.
Conclusions: The investigators concluded that chocolate consumption lowered blood pressure and risk of CVD, with a stronger association for stroke than for MI.
Perspective: This report adds to a growing body of literature related to chocolate and CVD health. Limitations of this particular study include the lack of information on the types of chocolate consumed such as dark chocolate. Further research related to specific components of chocolate would add to the information provided in this study. Elizabeth A. Jackson, M.D., F.A.C.C.

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Title: ACCF/ACR/AHA/ASNC/NASCI/SAIP/SCAI/SCCT 2010 Expert Consensus Document on Coronary Computed Tomographic Angiography: A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents
Topic: Noninvasive Cardiology
Date Posted: 4/7/2010
Author(s): Mark DB, Berman DS, Budoff MJ, et al.
Citation: J Am Coll Cardiol 2010;Mar 1:[Epub ahead of print].
Clinical Trial: No
Perspective: The following are 10 points to remember about coronary computed tomographic angiography (CTA).

1. This document presents an expert consensus overview of the current and emerging clinical uses of coronary CTA in patients with suspected or known coronary artery disease.

2. Multidetector CT (MDCT) technology prior to 64-channel or “slice” systems should now be considered inadequate for cardiac imaging (except for studies limited to assessing coronary calcium).

3. As with any diagnostic technology, coronary CTA has technical limitations with which users should be familiar, and proper patient selection and preparation are important to maximize the diagnostic accuracy of the test.

4. Overall sensitivity and specificity of 64-channel coronary CTA compared with invasive coronary angiography on a per-patient basis are both high, and the number of indeterminate studies due to inability to image important coronary segments in the select cohorts represented is <5%.

5. In the context of the emergency department evaluation of patients with acute chest discomfort, currently available data suggest that coronary CTA may be useful in the evaluation of patients presenting with an acute coronary syndrome (ACS) who do not have either acute electrocardiogram changes or positive cardiac markers.

6. At heart rates between 55 and 65 bpm, current 64-channel CT provides sufficient cine frame rates to provide left ventricular function information with accuracy comparable to other noninvasive and invasive modalities.

7. The evaluation of stents by MDCT is significantly more difficult than the evaluation of coronary artery segments without stents, even using current generation 64-channel MDCT scanners. In clinical studies, stent size was an important determinant of the results, with 100% of ≥3.5 mm, 80% of 3 mm, and 33% of <3 mm stents being judged assessable.

8. To date, there are no published trials evaluating the impact of specific therapy on clinical outcome in asymptomatic subjects identified as having only noncalcified atheroma by coronary CTA.

9. Routine use of a “triple rule-out” CT scan for ACS, acute aortic syndrome, and pulmonary embolism should not be used as a substitute for a careful clinical evaluation, with targeted testing for the most likely causes of the patient’s symptoms.

10. The typical doses of radiation reported to be associated with coronary CTA exceed those reported for invasive coronary angiography. Close monitoring of radiation exposure administered to patients is necessary to weigh the benefits of this noninvasive test and potential future unintended consequences and costs. Debabrata Mukherjee, M.D., F.A.C.C., Christopher P. Cannon, M.D., F.A.C.C.

Title: Mortality in Adult Congenital Heart Disease
Topic: Congenital Heart Disease
Date Posted: 4/7/2010
Author(s): Verheugt CL, Uiterwaal CS, van der Velde ET, et al.
Citation: Eur Heart J 2010;Mar 5:[Epub ahead of print].
Clinical Trial: No
Study Question: What are the mortality rates, modes of death, and risk factors for mortality in adults with congenital heart disease?
Methods: The Dutch CONCOR (CONgenital CORvitia) national registry was used and linked to the national mortality registry. The goal of the CONCOR registry is to facilitate the study of outcomes of patients with congenital heart disease. Between November 2001 and December 2009, over 11,400 patients greater than age 18 have been recruited into the database.
Results: Of 6,933 adults with congenital heart disease, 197 (2.8%) died during a follow-up of 24,865 patient-years. Excess mortality was seen in patients with congenital heart disease, particularly in the young. Median age of death was 48.8 years, with 77% dying of cardiovascular causes. The most common causes of death included chronic heart failure (26%) and sudden death (19%). Predictors of mortality included age, severity of defect, number of interventions, and number of complications. Complications particularly associated with increased risk included endocarditis, supraventricular arrhythmias, ventricular arrhythmias, conduction disturbances, myocardial infarction, and pulmonary hypertension (hazard ratio range, 1.4-3.1; p < 0.05).
Conclusions: Mortality is increased in adults with congenital heart disease, with the majority of deaths due to cardiovascular causes. Mortality is increased by the presence of various known complications of congenital heart disease.
Perspective: Knowledge of the risk factors for and causes of mortality in adults with congenital heart disease is important to developing risk-reducing management strategies. The Dutch CONCOR database has become an important tool in assessing outcomes for adults with congenital heart disease. It is imperative that other countries follow suit. Recent health care legislation adopted in the United States includes provisions for the development of a national registry for patients with congenital heart disease. Timothy B. Cotts, M.D., F.A.C.C.

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Title: Cognitive Deficits in Chronic Heart Failure
Topic: Heart Failure/Transplant
Date Posted: 4/7/2010
Author(s): Pressler SJ, Subramanian U, Kareken D, et al.
Citation: Nurs Res 2010;59:127-39.
Clinical Trial: No
Study Question: What are the types, frequency, and severity of cognitive deficits among patients with chronic heart failure (HF)? How are HF severity, age, and comorbidities related to these cognitive defects?
Methods: A sample of 414 participants completed the study (249 HF patients; 63 healthy and 102 medical participants). The HF patients completed measures of HF severity, comorbidity (multiple comorbidity, depressive symptoms), and neuropsychological functioning. Blood pressure and oxygen saturation were assessed at interview; clinical variables were abstracted from records. Participants in the comparison groups completed the same measures as the HF patients except those specific to HF.
Results: Compared with the healthy and medical participants, HF patients had poorer memory, psychomotor speed, and executive function. Significantly more HF patients (24%) had deficits in three or more domains. Higher (worse) HF severity was associated with more cognitive deficits; HF severity interacted with age to explain deficits in executive function. Surprisingly, men with HF had poorer memory, psychomotor speed, and visuospatial recall ability than women. Multiple comorbidity, hypertension, depressive symptoms, and medications were not associated with cognitive deficits in this sample.
Conclusions: HF results in losses of memory, psychomotor speed, and executive function in almost one fourth of patients. Patients with more severe HF are at risk for cognitive deficits. Older patients with more severe HF may have more problems in executive function, and men with HF may be at increased risk for cognitive deficits.
Perspective: The authors call for more studies designed to identify the mechanisms for the cognitive deficits observed in HF patients and to test innovative interventions to prevent cognitive decline. It is generally held that 25-50% of HF patients experience cognitive decline. HF patients and their families/caregivers are required to follow increasingly complex evidence-based regimens. This study and others raise issues around the impact of these cognitive deficits on self-care management and adherence to therapies. Suzanne Hughes, MSN, RN

Title: Quality of Care Among Obese Patients
Topic: General Cardiology
Date Posted: 4/6/2010 4:00:00 PM
Author(s): Chang VW, Asch DA, Werner RM.
Citation: JAMA 2010;303:1274-1281.
Clinical Trial: No
Study Question: What is the effect of patient weight status on common outpatient quality measures?
Methods: Eight different performance measures were examined in two national-level patient populations: 1) Medicare beneficiaries (n = 36,122) using data from the Medicare Beneficiary Survey (1994-2006); and 2) recipients of care from the Veterans Health Administration (VHA) (n = 33,550) using data from an ongoing performance-evaluation program (2003-2004). Performance measures among eligible patients for diabetes care (eye examination, glycated hemoglobin [HbA1c] testing, and lipid screening), pneumococcal vaccination, influenza vaccination, screening mammography, colorectal cancer screening, and cervical cancer screening were the main outcome measures. Measures were based on a combination of administrative claims, survey, and chart review data.
Results: The investigators found no evidence that obese or overweight patients were less likely to receive recommended care relative to normal-weight patients. Moreover, success rates were marginally higher for obese and/or overweight patients on several measures. The most notable differentials were observed for recommended diabetes care among Medicare beneficiaries: comparing obese versus normal-weight patients with diabetes, obese patients were more likely to receive recommended care on lipid screening (72% vs. 65%; odds ratio, 1.37; 95% confidence interval, 1.09-1.73) and HbA1c testing (74% vs. 62%; odds ratio, 1.73; 95% confidence interval, 1.41-2.11). All analyses were adjusted for sociodemographic factors, health status, clinical complexity, and visit frequency.
Conclusions: The authors concluded that among samples of patients from the Medicare and VHA populations, there was no evidence across eight performance measures that obese or overweight patients received inferior care when compared with normal-weight patients.
Perspective: Given that the majority of US adults are already overweight or obese, it is vitally important to ensure that these patients receive equitable and effective treatment. In the current study, the authors found no evidence in two large and important US patient populations that obese and overweight patients receive lower quality of care than normal-weight patients on common preventive services. Although underlying success rates for these performance measures were generally high across the board, they were nowhere near 100% and more work needs to be done to improve compliance with performance measures in both obese and nonobese patients. Debabrata Mukherjee, M.D., F.A.C.C.