Abul Kashem

Cardiovascular disease knowledge and risk perception among underserved individuals at increased risk of cardiovascular disease.

Background: Cardiovascular disease (CVD) risk factor awareness and knowledge are believed to be prerequisites for adopting healthy lifestyle behaviors. The purpose of this study was to examine knowledge of CVD risk factors and risk perception among individuals with high CVD risk. Methods: The sample consisted of inner city and rural medically underserved patients at high risk of CVD. To be eligible for the trial, subjects were required to have a 10% or greater CVD risk on the Framingham risk score. Knowledge of CVD was assessed with a 29-item questionnaire created for this study. Subjects also rated their perception of risk as compared with individuals of their own sex and age. Results: Data were collected from 465 subjects (mean [SD] age, 60.5 [10.1] years; mean [SD] Framingham risk score, 17.3% [9.5%]). The mean (SD) CVD knowledge score was 63.7% (14.6%), and mean (SD) level of risk perception was 0.35 (1.4). Men and women had similar Framingham risk scores, but women perceived their risk to be significantly higher than that of their male counterparts. Women were also more knowledgeable than men about CVD. Urban participants had significantly higher actual risks than did their rural counterparts (18.2% [10.7%] vs 16.0% [8.9%], respectively; P = .01) but were significantly less knowledgeable about heart disease and also perceived their risk to be lower. Conclusions: These results indicate a low perception of risk and cardiovascular knowledge especially among men and inner city residents. Innovative educational strategies are needed to increase risk factor knowledge and awareness among at-risk individuals.

Managing Heart Failure Care Using an Internet-Based Telemedicine System

BACKGROUND Managing patients with heart failure (HF) is labor intensive, and follow-up is often inadequate to detect day-to-day changes that ultimately lead to decompensation. We tested the effect of an Internet-based telemedicine (T) system that provides frequent surveillance and increased communicate between HF patients and their provider on frequency of hospitalization in a cohort of patients with advanced HF. METHODS AND RESULTS HF patients in NYHA Class II-IV were randomized to usual care (UC, n = 24) or T (T plus UC, n = 24) and followed for 1 year. Office visits, emergency department visits, hospitalizations, telephone calls, and number of Internet communications were measured over the 1-year period. Left ventricular ejection fraction (EF) was assessed by echocardiography in both groups. For T, mean age was 53.2 +/- 2.0 years (72% male, 61% Caucasian, 39% African American). For UC, mean age was 54.1 +/- 2.6 years (76% male, 72% Caucasian, 14% African American, and 14% Hispanic). HF etiologies and EF were similar in both groups. During the 12-month period, UC had 74 total phone calls to the practice, whereas T had 88 telephone calls plus 1887 telemedicine data messages (6.5 messages/patient/month). ER visits were lower in the T group (T 5, UC 12; P < .05). Hospital admissions (T 24, C 40; P = .025) and total hospital days (T 84, UC 226 days; P < .005) were lower in T. Unscheduled clinic visits (T 13, UC 13; P = NS) and scheduled clinic visits (T 78, UC 94; P = NS) were similar in both groups. CONCLUSIONS Frequent monitoring and patient management using a telemedicine system may help to reduce hospitalizations, hospital days, and emergency department visits.

Endothelial-Dependent Flow-Mediated Dilation in African Americans With Masked-Hypertension

BACKGROUND Office-blood pressure (BP) measurements alone overlook a significant number of individuals with masked-hypertension (office-BP: 120/80-139/89 mm Hg and 24-h ambulatory BP monitoring (ABPM) daytime ≥135/85 mm Hg or night-time ≥120/70 mm Hg). Diminished endothelial function contributes to the pathogenesis of hypertension. To better understand the pathophysiology involved in the increased cardiovascular (CV) disease risk associated with masked-hypertension, we estimated the occurrence, assessed the endothelial function, compared plasma levels of inflammatory markers, white blood cell count (WBC count), tumor necrosis factor-α (TNF-α), and high sensitivity C-reactive protein (hsCRP) and examined the possible relationship between endothelial function and inflammatory markers in apparently healthy prehypertensive (office-BP: 120/80-139/89 mm Hg) African Americans. METHODS Fifty African Americans who were sedentary, nondiabetic, nonsmoking, devoid of CV disease were recruited. Office-BP was measured according to JNC-7 guidelines to identify prehypertensives in whom ABPM was then assessed. Fasting plasma samples were assayed for inflammatory markers. Brachial artery flow-mediated dilation (FMD) at rest and during reactive hyperemia was measured in a subset of prehypertensives. RESULTS Subjects in the masked-hypertension sub-group had a higher hsCRP (P = 0.04) and diminished endothelial function (P = 0.03) compared to the true-prehypertensive sub-group (office-BP: 120/80-139/89 mm Hg and ABPM: daytime <135/85 mm Hg or night-time <120/70 mm Hg). Regression analysis showed that endothelial function was inversely related to hsCRP amongst the masked-hypertensive sub-group (R(2) = 0.160; P = 0.04). CONCLUSIONS Masked-hypertension was identified in 58% of African Americans which suggests that a masking phenomenon may exist in a sub-group of prehypertensives who also seem to have a diminished endothelial function that could be mediated by an elevated subclinical inflammation leading to the increased CV disease.

Accuracy of Blood Pressure Measurements Transmitted Through a Telemedicine System in Underserved Populations

In underserved populations, inadequate surveillance and treatment allows hypertension to persist until actual cardiovascular events occur. Thus, we developed an Internet-based telemedicine system to address the suboptimal control of hypertension and other modifiable risk factors. To minimize cost, the subjects used home monitors for blood pressure (BP) measurements and entered these values into the telemedicine system. We hypothesized that patients could accurately measure their BP and transmit these values via a telemedicine system. Inner city and rural subjects (N = 464; 42% African-American or Hispanic) with 10% or greater 10-year risk of cardiovascular disease and with treatable risk factors were randomized into two groups, control group (CG) and telemedicine group (TG). Each subject received a home sphygmomanometer with memory. The TG recorded and entered BP at least weekly. During office visits, the BP meters were downloaded and recorded BP compared to BP values transmitted via telemedicine. The telemedicine (T) BP values were similar to the meter recorded (R) values (T: systolic/diastolic BP 133.4 +/- 11.1/77.5 +/- 6.8 mm Hg, and R: systolic/diastolic BP 136.4 +/- 11.9.4/79.7 +/- 7.5 mm Hg). The percent error was <1% for both systolic (-0.02 +/- 0.04%) and diastolic (-0.03 +/- 0.04%) BP. Lastly, the telemedicine BP values were similar to the office (O) BP values for systolic and diastolic BP (T: systolic/diastolic BP 133.4 +/- 11.1/77.5 +/- 6.8 mm Hg, and O: systolic/diastolic BP 136.3 +/- 20.5/78.1 +/- 10.5 mm Hg). In underserved populations, this inexpensive approach of patients using a home monitor and entering these values into a telemedicine system provided accurate BP data.

Gender differences in cardiovascular risk factors and risk perception among individuals with diabetes.

Purpose The purpose of this study was to examine gender-based differences in cardiovascular risk factors and risk perception among individuals with diabetes. Methods The sample consisted of patients with an established history of diabetes who were enrolled in a telemedicine trial to reduce cardiovascular disease (CVD) risk. All subjects had a 10% or greater risk on the Framingham risk index. Assessments included blood pressure, A1C, lipid profile, medication history, and knowledge and risk perception surveys. Results Data were available for 211 individuals with type 2 diabetes (88 men and 123 women). The women and men did not differ in age, body mass index, or Framingham risk. Only 37.4% of women and 40.9% of men were at an A1C target of <7%. Total cholesterol levels were significantly higher among women, and fewer women were at low-density lipoprotein or blood pressure targets. Knowledge of CVD was similar between the 2 sexes. However, women perceived their risk for CVD to be significantly higher than did men. Conclusion Less favorable cardiovascular risk profiles are observed among women with diabetes as compared with their male counterparts. Multifaceted approaches to both diabetes management and education are needed to target CVD risk reduction among individuals with diabetes.

CardioClasp: a new passive device to reshape cardiac enlargement.

In dilated heart failure, geometric distortions place an extra load on the myocardial cells. If this extra burden can be eliminated, the myocardial wall stress would decrease leading to improved systolic ventricular performance. In a dilated heart failure model, we wanted to see whether the CardioClasp™ (which uses two indenting bars to reshape the left ventricle [LV] as two widely communicating “lobes” of reduced radius) could improve systolic performance by passively reshaping the LV and reducing the wall stress.In mongrel dogs (n = 7; 25–27 kg), rapid ventricular pacing (210 ppm 1st week to 240 ppm 4th week) induced dilated heart failure. After 4 weeks, LV performance was evaluated at baseline and with the CardioClasp™ by measuring LV end-diastolic and peak LV systolic pressure, LV +dP/dt, LV −dP/dt, and cardiac output. With the Clasp on, LV wall stress was reduced to 58.6 ± 3.5 from 108.3 ± 8.2 g/cm2. The fractional area of contraction (FAC) with the Clasp on (28.4 ± 4.4) was significantly increased (p < 0.05) from baseline (20.8 ± 4.6) and consistent with improved systolic performance. Cardiac output, LV peak systolic and end-diastolic pressures, and regional myocardial blood flow were unaltered.The Clasp was able to acutely reshape the left ventricle, while preserving the contractile mass, and reduced the tension on the myocardial cells and increased the fractional area of contraction without decreasing the systolic blood pressure.

Enhanced blood pressure variability in a high cardiovascular risk group of African Americans: FIT4Life Study

High blood pressure (BP) levels in African Americans elicit vascular inflammation resulting in vascular remodeling. BP variability (BPV) correlates with target organ damage. We aimed to investigate the relationship between inflammatory markers and BPV in African Americans. Thirty-six African Americans underwent 24-hour ambulatory BP monitoring (ABPM). BPV was calculated using the average real variability index. Fasting blood samples were assayed for high-sensitivity C-reactive protein (hs-CRP), tumor necrosis factor-alpha (TNF-alpha), and white blood cell (WBC) count. Significant associations between hs-CRP and 24-hour systolic variability (r=0.50; P=.012) and awake systolic variability (r=0.45; P=.02) were identified after adjusting for age, body mass index, and 24-hour mean BP. ABPM variables were compared between the hs-CRP tertile groups. In post-hoc analysis, there was a significant difference in 24-hour and awake periods for both systolic and diastolic variability among the groups. TNF-alpha and WBC count showed no associations with ABPM variables. hs-CRP was associated with systolic variability, and higher levels of hs-CRP were related with greater BPV. Higher inflammatory status influences wider fluctuations in systolic BP, which in turn could facilitate early progression to target organ damage independent of absolute BP levels in African Americans.

Research ArticleEnhanced blood pressure variability in a high cardiovascular risk group of African Americans: FIT4Life Study

High blood pressure (BP) levels in African Americans elicit vascular inflammation resulting in vascular remodeling. BP variability (BPV) correlates with target organ damage. We aimed to investigate the relationship between inflammatory markers and BPV in African Americans. Thirty-six African Americans underwent 24-hour ambulatory BP monitoring (ABPM). BPV was calculated using the average real variability index. Fasting blood samples were assayed for high-sensitivity C-reactive protein (hs-CRP), tumor necrosis factor-alpha (TNF-alpha), and white blood cell (WBC) count. Significant associations between hs-CRP and 24-hour systolic variability (r=0.50; P=.012) and awake systolic variability (r=0.45; P=.02) were identified after adjusting for age, body mass index, and 24-hour mean BP. ABPM variables were compared between the hs-CRP tertile groups. In post-hoc analysis, there was a significant difference in 24-hour and awake periods for both systolic and diastolic variability among the groups. TNF-alpha and WBC count showed no associations with ABPM variables. hs-CRP was associated with systolic variability, and higher levels of hs-CRP were related with greater BPV. Higher inflammatory status influences wider fluctuations in systolic BP, which in turn could facilitate early progression to target organ damage independent of absolute BP levels in African Americans.

Early and late results of left ventricular reshaping by passive cardiac-support device in canine heart failure.

BACKGROUND We tested whether the CardioClasp, a passive non-blood-contacting device could decrease excessive geometric burden in dilated cardiomyopathy and improve left ventricular systolic function and contractility by reshaping the left ventricle (LV) and by decreasing LV wall stress (LVWS) without decreasing arterial blood pressure. METHODS In mongrel dogs (n = 6, the early group; n = 6, the chronic group; 25-27 kg), 4 weeks of rapid right ventricular pacing (210 to 240 bpm) induced dilated cardiomyopathy with heart failure. In the early group, we used hemodynamic data and echocardiography to evaluate LV systolic function immediately after placing the CardioClasp device. In the chronic group, we also evaluated LV systolic function immediately after placing the device on dilated hearts and then left the device in place for 30 days. At the end of 30 days, before explantation of the device, we again assessed LV systolic function. We measured fractional area of contraction (FAC), LVWS, and hemodynamic data in both groups. RESULTS In the early group, use of the CardioClasp device decreased the LV end-diastolic anterior-to-posterior dimension by 27.8% +/- 2.6% at implantation (p < 0.05). In the chronic group, use of the CardioClasp decreased the LV end-diastolic anterior-to-posterior dimension by 19.4% +/- 2.0% at implantation (p < 0.05) and by 22.0% +/- 3.10% at explantation (p < 0.05). Use of the CardioClasp did not alter LV end-diastolic and peak pressure, LV dP/dts, or cardiac output at implantation or at explantation. In the early group, use of the CardioClasp decreased the LVWS by 43.4% +/- 3.1% at implantation (p < 0.05). In the chronic group, LVWS decreased by 28.8% +/- 2.1% at implantation (p < 0.05) and by 43.3% +/- 5.2% at explantation (p < 0.05). In the early group, FAC increased significantly, by 28.9% +/- 7.8% at implantation (p < 0.05). In the chronic group, FAC increased significantly, by 18% +/- 12% at implantation (p < 0.05) and by 19% +/- 12% at explantation (p < 0.05). CONCLUSIONS As expected, use of the CardioClasp device increased FAC and decreased LVWS by reshaping the LV. Use of the CardioClasp device maintained cardiac output and arterial pressure. In 30-day experiments, the increased FAC and decreased LVWS were maintained at explantation.

Vascular delay and intermittent stimulation: keys to successful latissimus dorsi muscle stimulation

BACKGROUND The goal of this study was to obtain physiologically significant increases in peak left ventricular (LV) systolic pressure and stroke volume with latissimus dorsi muscle (LDM) stimulation in cardiomyoplasty (CMP). We hypothesized that preserving LDM integrity by vascular delay and intermittent stimulation would significantly increase LDM cardiac assistance. METHODS In 4 control dogs and 12 dogs that had undergone a vascular delay (VD) procedure, LV dysfunction was induced by intracoronary microsphere injections. Cardiomyoplasty surgery was performed 14 days later, followed by progressive LDM conditioning. In the control dogs and in 6 of the VD dogs, the LDM was stimulated 24 hours per day (VD plus constant stimulation [CS]). In the other 6 VD dogs, LDMs were stimulated on a daily schedule of 10 hours on and 14 hours off (VD plus interrupted stimulation [IS]). Latissimus dorsi muscle stimulated beats were compared with nonstimulated beats 9 weeks later. RESULTS In the control dogs, LDM stimulation had minimal effects. In VD + CS and VD + IS, LDM stimulation increased peak LV pressure, stroke volume, stroke work, and stroke power (p < 0.05). However, these changes were greater in the VD + IS group, in which LDM stimulation increased peak aortic pressure by 17.6 +/- 1.7 mm Hg, peak LV pressure by 19.7 +/- 1.1 mm Hg, peak positive LV dp/dt by 398 +/- 144 mm Hg per second, stroke volume by 5.1 +/- 0.7 mL, stroke work by 10.9 +/- 0.9 gm.m, and stroke power by 122.7 +/- 11.6 gm.m per second (p < 0.05 compared with VD + CS). Quantitative morphometric analysis showed minimal LDM degeneration in the VD + IS group (7.5% +/- 1.1%), and VD + CS group (10.5% +/- 4.5%) compared with the control group (29.5% +/- 4.5%, p < 0.05). CONCLUSIONS VD and IS considerably increased the LV assistance with LDM stimulation. Further studies of this combined approach to CMP should be planned.