Hari Prasad

Metabolic Syndrome: Definition and Therapeutic Implications

Abstract The collection of impaired glucose metabolism, central obesity, elevated blood pressure, and dyslipidemia is identified as metabolic syndrome (MetS). It is estimated that approximately 25% of the worlds population has MetS. In the United States, MetS is more common in men and Hispanics, and its incidence increases with age. Metabolic syndrome increases the risk of developing cardiovascular disease and type 2 diabetes mellitus. The underlying risk factors include insulin resistance and abdominal obesity. Confusion about MetS exists in part due to the lack of a consensus definition and treatment protocol. Treatment of MetS begins with therapeutic lifestyle changes and then pharmacologic treatment of the syndromes individual components. Effective interventions include diet modification, exercise, and use of pharmacologic agents to treat risk factors. Weight loss and increasing physical activity significantly improve all aspects of MetS. A diet that includes more fruits, vegetables, whole grains, monounsaturated fats, and low–fat dairy products will benefit most patients with MetS. Physicians can be most effective in advising patients by customizing specific lifestyle recommendations after assessing patients for the presence of risk factors.

Influence of Predictive Modeling in Implementing Optimal Heart Failure Therapy

Introduction:A gap remains between evidence-based guidelines in the treatment of heart failure (HF) and current pharmacologic and device therapy. The Seattle Heart Failure Model (SHFM) is an accurate predictive tool that allows the clinician to quantitatively assess the influence of pharmacologic and device therapy on HF. The authors hypothesized that graphically demonstrating the improvement in survival using such a tool may well modify physician practice behavior. Methods:The authors examined 50 randomly selected patients from 10 primary care physicians having HF with a left ventricular ejection fraction <40%. Twenty-one data elements were entered into the SHFM to create a survival estimate before and after implementation of interventions known to be beneficial, both pharmacologic (addition of angiotensin-converting enzyme/angiotensin receptor blocker, statin, &bgr;-blocker and aldosterone blocker) and device based (consideration for automatic implantable cardioverter-defibrillator, biventricular pacer and biventricular implantable cardioverter-defibrillator). The influence of therapeutic change was presented in a focused clinical session with the primary care physician. Results:The mean age of the population examined was 73 ± 10 years with New York Heart Association class 2.2 ± 0.5 symptoms. In the 50 patients examined, the authors altered device or medical therapy in 82%. This included advancement of medical therapy in 50%, consideration for device referral in 10% or both (medical therapy and device referral) in 22%. This augmentation of therapy resulted in an increase in estimated mean life expectancy from 8.8 to 10.9 years (P < 0.001). Conclusion:Use of the SHFM significantly impacted intensification of HF therapy in this ambulatory HF population.

Renal Artery Stenosis-An Update

Abstract Renal artery stenosis (RAS) is a common form of peripheral arterial disease. The most common cause of RAS is atherosclerosis. It is predominantly unilateral. The pathophysiologic mechanism stems from renal underperfusion resulting in the activation of the renin- angiotensin-aldosterone pathway. Even though the majority of patients with RAS are asymptomatic, it can clinically present with hypertension, nephropathy and congestive heart failure. This progressive disease can lead to resistant hypertension and end stage kidney failure. Screening patients for RAS with either Doppler ultrasonography, computed tomographic angiography, or magnetic resonance angiography is preferred. Adequate blood pressure control, goal-directed lipid-lowering therapy, smoking cessation, and other preventive measures form the foundation of management of patients with RAS. Catheter-based percutaneous revascularization with angioplasty and stenting showed modest clinical benefit for patients in small retrospective studies, but data from randomized clinical trials failed to confirm these beneficial results. The current ongoing Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial may provide more concrete data regarding the role of stenting in RAS. Surgical revascularization is considered only if catheter-based revascularization is unsuitable or unsuccessful. The American College of Cardiology/American Heart Association guidelines on evaluation and management of patients with RAS provide the framework for determining individualized assessment and treatment plans for patients with RAS.

Have We Given Up on Intra‐aortic Balloon Counterpulsation in Post–Myocardial Infarction Cardiogenic Shock?

The recently published Intra‐aortic Balloon Pump in Cardiogenic Shock II (IABP‐SHOCK II) trial concluded that intra‐aortic counterpulsation (IACP) does not reduce 30‐day mortality in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI) for whom early revascularization strategy was planned. The study resulted in downgrading IACP in post‐AMI CS patients by certain professional organizations like the European Society of Cardiology. Although this is the largest and most important CS study of this decade, it suffers from considerable shortcomings: (1) time intervals from chest‐pain onset or AMI recognition to revascularization, enrollment, and IACP initiation are not disclosed; (2) 86.6% of the treatment arm initiated IACP only post–percutaneous coronary intervention (PCI), and 4.3 % did not receive IACP at all; (3) 17.4% of the control arm crossed over to IACP or other mechanical support, mostly due to protocol violations; (4) there is no adjudication of the mortality events; (5) follow‐up is limited to 30 days; and (5) both methodology (especially IACP device size) and quality of IACP are not evaluated and documented. Because the study assessed mostly the efficacy and safety of IACP initiated post‐PCI, the study conclusions should not be extrapolated to IACP pre‐PCI or during PCI in CS. Moreover, IACP had a favorable effect on the mortality of younger patients. Intra‐aortic counterpulsation should remain the first line of mechanical circulatory support for the hemodynamically compromised AMI patients with or without CS who are undergoing primary PCI. Early upgrade to more advanced mechanical circulatory support should be considered for selective suitable candidates who remain in refractory CS despite revascularization and IACP.

Influence of Predictive Modeling in Implementing Optimal Heart Failure Therapy in Inpatient Setting

Explanatory factor for readmission % of Patients identifying factor as a cause of readmission (n5105) % of Readmitting Providers identifying factor as a cause of readmission (n5100) % of Discharging Providers identifying factor as a cause of readmission (n597) Patient vs. Readmitting Provider (McNemar p-value, Kappa statistic, Kappa p-value) Patient vs. Discharging Provider (McNemar p-value, Kappa statistic, Kappa p-value) Discharing Provider vs. Readmitting Provider (McNemar p-value, Kappa statistic, Kappa p-value)