Anekwe Onwuanyi

Is telemetry overused? Is it as helpful as thought?

Cardiac telemetry is widely used in hospitals, but it is expensive and labor-intensive. Therefore, it should be used only in those most likely to benefit. The authors review the available evidence and offer their recommendations. Cardiac telemetry is widely used in hospitals, but it is expensive and labor-intensive. Therefore, it should be used only in those most likely to benefit.

Race, exercise training, and outcomes in chronic heart failure: Findings from Heart Failure - A Controlled Trial Investigating Outcomes in Exercise TraiNing (HF-ACTION)

BACKGROUND The strength of race as an independent predictor of long-term outcomes in a contemporary chronic heart failure (HF) population and its association with exercise training response have not been well established. We aimed to investigate the association between race and outcomes and to explore interactions with exercise training in patients with ambulatory HF. METHODS We performed an analysis of HF-ACTION, which randomized 2331 patients with HF having an ejection fraction ≤35% to usual care with or without exercise training. We examined characteristics and outcomes (mortality/hospitalization, mortality, and cardiovascular mortality/HF hospitalization) by race using adjusted Cox models and explored an interaction with exercise training. RESULTS There were 749 self-identified black patients (33%). Blacks were younger with significantly more hypertension and diabetes, less ischemic etiology, and lower socioeconomic status versus whites. Blacks had shorter 6-minute walk distance and lower peak VO2 at baseline. Over a median follow-up of 2.5 years, black race was associated with increased risk for all outcomes except mortality. After multivariable adjustment, black race was associated with increased mortality/hospitalization (hazard ratio [HR] 1.16, 95% CI 1.01-1.33) and cardiovascular mortality/HF hospitalization (HR 1.46, 95% CI 1.20-1.77). The hazard associated with black race was largely caused by increased HF hospitalization (HR 1.58, 95% CI 1.27-1.96), given similar cardiovascular mortality. There was no interaction between race and exercise training on outcomes (P > .5). CONCLUSIONS Black race in patients with chronic HF was associated with increased prevalence of modifiable risk factors, lower exercise performance, and increased HF hospitalization, but not increased mortality or a differential response to exercise training.

Benefit of exercise therapy for systolic heart failure in relation to disease severity and etiology—findings from the Heart Failure and A Controlled Trial Investigating Outcomes of Exercise Training study

BACKGROUND This post hoc analysis of the HF-ACTION cohort explores the primary and secondary results of the HF-ACTION study by etiology and severity of illness. METHODS HF-ACTION randomized stable outpatients with reduced left ventricular (LV) function and heart failure (HF) symptoms to either supervised exercise training plus usual care or to usual care alone. The primary outcome was all-cause mortality or all-cause hospitalization; secondary outcomes included all-cause mortality, cardiovascular mortality or cardiovascular hospitalization, and cardiovascular mortality or HF hospitalization. The interaction between treatment and risk variable, etiology or severity as determined by risk score, New York Heart Association class, and duration of cardiopulmonary exercise test was examined in a Cox proportional hazards model for all clinical end points. RESULTS There was no interaction between etiology and treatment for the primary outcome (P = .73), cardiovascular (CV) mortality or CV hospitalization (P = .59), or CV mortality or HF hospitalization (P = .07). There was a significant interaction between etiology and treatment for the outcome of mortality (P = .03), but the interaction was no longer significant when adjusted for HF-ACTION adjustment model predictors (P = .08). There was no significant interaction between treatment effect and severity, except a significant interaction between cardiopulmonary exercise duration and training was identified for the primary outcome of all-cause mortality or all-cause hospitalization. CONCLUSION Consideration of symptomatic (New York Heart Association classes II to IV) patients with HF with reduced LV function for participation in an exercise training program should be made independent of the cause of HF or the severity of the symptoms.

Hypertensive Vascular Disease as a Cause of Death in Blacks Versus Whites: Autopsy Findings in 587 Adults

Cardiovascular disease is the major cause of excess mortality among urban US blacks, but autopsy data comparing black-white differences in underlying pathological causes of cardiovascular death are lacking. We reviewed all 720 adult cases autopsied in 1991 in the New York City Medical Examiners Office in which the coded cause of death was cardiovascular disease (International Classification of Diseases, 9th Revision, codes 391, 393 to 398, 401 to 404, 410, 411, 414 to 417, 420 to 438, and 440 to 444). After exclusion of 133 cases because race was missing or coded as other than black or white, gender was not coded, or there was an unusual circumstances of death or extreme obesity, 587 cases were available for analysis. There were 314 black and 273 white subjects. Black women were younger than white women at time of death (mean age, 54.7 versus 61.5 years; P<.001), whereas black and white men did not differ in mean age at death. Hypertensive vascular disease was the autopsy cause of death in 42% of blacks compared with 23% of whites (P<.001). Conversely, atherosclerotic heart disease was the autopsy cause of death in 64% of white subjects but only 38% of blacks. These patterns were consistent in both sexes and after adjustment for age. Hypertensive vascular disease was far more common than atherosclerotic heart disease as the cause of death at autopsy among blacks compared with whites in New York City, whereas atherosclerotic heart disease was more common in whites. These findings suggest that ineffective control of hypertension is a major factor contributing to excess cardiovascular mortality among urban blacks.

Impact of peripheral arterial disease on functional limitation in congestive heart failure: results from the national health and nutrition examination survey (1999-2004).

Background. Peripheral arterial disease (PAD) often coexists with congestive heart failure (CHF) and can be masked by symptoms of CHF such as functional limitation (FL), a common manifestation for both. Therefore, we sought to estimate the prevalence of PAD and its independent association with FL in CHF. Methods. We conducted a cross-sectional study on National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2004 to quantify weighted prevalence of CHF and PAD. Study cohort consisted of 7513, with ankle brachial index (ABI) measurements at baseline. Independent association of PAD (ABI ≤ 0.9) with FL in CHF was determined with multivariate logistic regression (MVLR). Results. Overall weighted PAD prevalence was 5.2%. CHF was present in 305 participants, and the weighted prevalence of PAD in this subgroup was 19.2%. When compared, participants with CHF and PAD were more likely to be older (P < 0.001), hypertensive (P = 0.005) and hypercholesterolemic (P = 0.013) than participants with CHF alone. MVLR showed that PAD (adjusted OR = 5.15; 95% CI: 2.2, 12.05: P < 0.05) and arthritis (adjusted OR = 2.36; 95% CI: 1.10, 5.06: P < 0.05) were independently associated with FL in CHF. Conclusion. Independent association of PAD with FL suggests the need for reinforced screening for PAD in individuals with CHF.

Evaluation of Telemetry Utilization, Policy, and Outcomes in an Inner-City Academic Medical Center

OBJECTIVE To evaluate the appropriateness and intermediate outcomes of telemetry admissions. METHODS We abstracted demographic and clinical data from records of all new telemetry admissions during a 2-month period. To determine appropriateness, 2 authors classified patients using the American College of Cardiology (ACC) guidelines and our telemetry policy. Other utilization and outcome measures were assessed. Agreement between both guidelines was computed (kappa coefficient). Categorical group covariates were compared using chi2 test. Variations in telemetry length of stay (LOS) were compared using Mann-Whitney and Kruskal-Wallis tests. LOS predictors were ascertained by multiple regression analysis. RESULTS Of the 120 patients, appropriate admission was 81.6% (ACC criteria) and 83% by our criteria. Guidelines interrater reliability was .89 (kappa). Telemetry events incidence was 33.3%, with 5.8% major and 27.5% minor. LOS was longer among major than minor events group(7.8 vs. 3.4 days, p = .01). Type of telemetry event was a predictor of LOS (p = .0001). The occurrence of a major telemetry event was associated with cardiology consultation (p = .03). CONCLUSIONS Appropriate telemetry admission was observed in more than 80% of cases. Our telemetry policy had very good agreement with standard guideline. However, the low rate of major telemetry events in all patient groups suggests current guidelines might have considerable limitations.

Coarctation of Aorta With Normal Blood Pressure

Coarctation of aorta (COA) in adults usually manifests as uncontrolled severe hypertension, which may cause symptoms of heart failure, headaches, epistaxis, or aortic dissection. We report an unusual case of coarctation of the aorta in a young male associated with normal blood pressure.

Effect of Digoxin Use Among Medicaid Enrollees With Atrial Fibrillation

Background— Recently published analysis of contemporary atrial fibrillation (AF) cohorts showed an association between digoxin and increased mortality and hospitalizations; however, other studies have demonstrated conflicting results. Many AF cohort studies did not or were unable to examine racial differences. Our goal was to examine risk factors for hospitalizations and mortality with digoxin use in a diverse real-world AF patient population and evaluate racial differences. Methods and Results— We performed a retrospective cohort analysis of claims data for Medicaid beneficiaries, aged 18 to 64 years, with incident diagnosis of AF in 2008 with follow-up until December 31, 2009. We created Kaplan–Meier curves and constructed multivariable Cox proportional hazard models for mortality and hospitalization. We identified 11 297 patients with an incident diagnosis of AF in 2008, of those, 1401 (12.4%) were on digoxin. Kaplan–Meier analysis demonstrated an increased risk of hospitalization with digoxin use overall and within race and heart failure groups. In adjusted models, digoxin was associated with an increased risk of hospitalization (adjusted hazard ratio, 1.54; 95% confidence interval, 1.39–1.70) and mortality (adjusted hazard ratio, 1.50; 95% confidence interval, 1.05–2.13). Overall, blacks had a higher risk of hospitalization but similar mortality when compared with whites regardless of digoxin use. We found no significant interaction between race and digoxin use for mortality (P=0.4437) and hospitalization (P=0.7122). Conclusions— Our study demonstrates an overall increased risk of hospitalizations and mortality with digoxin use but no racial/ethnic differences in outcomes were observed. Further studies including minority populations are needed to critically evaluate these associations.

Long-term outcome of isolated coronary artery bypass surgery in blacks

Objective: There are conflicting data on the influence of race and gender on the outcome of patients undergoing coronary artery bypass graft surgery (CABG), with blacks and females showing higher operative mortality (OM) in some series and not others. Materials and Methods: The medical records of 176 black patients undergoing isolated CABG by a single surgeon from 2000 to 2014 were retrospectively reviewed. The mean age was 61.9 ± 11.2 years and majority 93 (52.8%) were males. Identified risk profiles were peripheral vascular disease 53 (30.1%) patients, insulin-dependent diabetes mellitus 49 (27.8%), end-stage renal disease (ESRD) 27 (15.3%), chronic obstructive pulmonary disease 27 (15.3%), cerebrovascular disease 24 (13.6%), and HIV/AIDS 5 (2.8%). One hundred and forty (79.5%) had severe triple vessel disease, 30 (17.0%) left main disease, and ejection fraction mean 43.0 ± 14.3. Results: One hundred and twenty-eight patients (72.7%) underwent on-pump and 48 patients (27.3%) off-pump coronary artery bypass graft (OPCAB), with 150 (85.2%) urgent surgeries. EuroSCORE-II (ES-II) score was 3.86 ± 3.18 while observed OM was 6.81% (12/176). There was no difference in OM between males and females 6.45% versus 7.22% ( P = 0.924) and on-pump and OPCAB 7.81% versus 4.16% ( P = 0.604). Univariate analysis identified ESRD and ES as predictors but on multivariate analysis only ESRD with odds ratio 4.630 (95% CI: 1.321-16.229, P = 0.017). The society of thoracic surgeons (STS) quality measurement task force major complications were acute kidney injury 6.81%, prolonged ventilation 6.81%, stroke 3.40%, deep sternal wound infection 2.27%, and reoperation 1.70%. Overall 1 and 5 years survival was 90.0% and 73.9%, respectively, with no significant difference between males and females 92.4% and 75.0% versus 86.4% and 70.9%, respectively, when P = 0.764. Conclusion: The observed/expected 1.76 ratio may partly be due to higher number of urgent and ESRD patients of 85.2% and 15.3% compared to 27.9% and 2.36-7.90%, respectively, in the STS database. Our ESRD patients had 4΍ times odds of death than non-ESRD. Despite males having slightly higher risk profiles, long-term survival was similar with females and overall 1 and 5 years survival comparable to blacks in other series.

CARDIOVASCULAR DISEASE AMONG US ADULT MARIJUANA USERS: NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY, 2011-2012

Marijuana is the most commonly abused drug in US. Studies have shown that cannabinoids up regulates pro-inflammatory cytokines and thrombogenesis which aids progression of atherosclerotic disease and lowers angina threshold. Our aim was to evaluate the association between marijuana and