Harvey S. Hahn

Quantitative left ventricular systolic function: from chamber to myocardium.

One of the most common indications for obtaining a Doppler echocardiographic study is to ascertain left ventricular (LV) systolic function. There are many ways in which LV function can be determined, but an important assumption that is often overlooked is that every measure that we commonly use is only a surrogate marker of LV function due to the fact that it is impossible to characterize the complex geometric and volumetric function of the ventricle (or myocyte) in a single number. Stated in another way, there is no one perfect measure of LV function. The ejection fraction has emerged as the preeminent method to express LV performance, but although ejection fraction is universally accepted, there are a number of other techniques that can assess LV function and, when taken together, provide a more comprehensive picture both of global and regional LV function. Each of these measures (including ejection fraction) has variable dependence on loading conditions, heart rate, and geometric position that limits its accuracy. Understanding the limitations of each measure will allow the physician to more intelligently understand the true status of the myocardium.

Heart Failure Performance Measures: Do They Have an Impact on 30-Day Readmission Rates?

Congestive heart failure (CHF) accounts for more health care costs than any other diagnosis. Readmissions contribute to this expenditure. The authors evaluated the relationship between adherence to performance metrics and 30-day readmissions. This was a retrospective study of 6063 patients with CHF between 2001 and 2008. Data were collected for 30-day readmissions and compliance with CHF performance measures at discharge. Rates of readmission for CHF increased from 16.8% in 2002 to 24.8% in 2008. Adherence to performance measures increased concurrently from 95.8% to 99.9%. Except for left ventricular function (LVF) assessment, the 30-day readmission rate was not associated with adherence to performance measures. Readmitted patients had twice the odds of not having their LVF assessed (odds ratio = 2.0; P < .00005; 95% confidence interval = 1.45-2.63). CHF performance measures, except for the LVF assessment, have little relationship to 30-day readmissions. Further studies are needed to identify performance measures that correlate with quality of care.

The Prevalence of Borderline Personality Disorder in a Consecutive Sample of Cardiac Stress Test Patients

To the Editor: There are a number of empirical studies that have examined prevalence rates of borderline personality disorder (BPD) in various medical syndromes. Elevated rates of BPD have been associated with somatoform and fictitious disorders1; somatic preoccupation2; medically self-harming behavior among both psychiatric inpatients3 and internal medicine outpatients4; interference with wound healing5; chronic pain sydnromes6; various other “syndrome-like” conditions (eg, chronic fatigue, fibromyalgia) as well as osteoarthritis, diabetes, and hypertension7; and medical disorders such as hypertension, hepatic disease, cardiovascular disease, and “any assessed medical condition.”8 However, several studies report rates of BPD in specific medical populations that are comparable to rates for the disorder encountered in the general population (eg, various pain syndromes,9,10 pain medication use,11 and various psychophysiologic disorders10). Indeed, the factors that influence associations between BPD and various medical phenomena are poorly understood. In this study, we examined the prevalence of BPD in a consecutive sample of cardiac stress test patients to determine if cardiac symptoms might be overrepresented among individuals with BPD. Method. Participants in this study were consecutive male or female patients aged 18 years or older undergoing cardiac stress testing in a community hospital from June 6, 2010, to September 3, 2010. The sample was drawn from a middle-to-high socioeconomic suburb of a medium-sized midwestern city. Exclusion criteria were medical (eg, pain), psychiatric (eg, psychosis), or intellectual disturbances that would preclude the successful completion of a survey booklet. Two recruiters approached 302 candidates and enrolled 251 participants, for a response rate of 83.1%. Among the 251 participants, 118 were male and 133 female; age ranged from 20 to 91 years (mean = 58.00, SD = 13.85). The large majority were white (93.2%), followed by black (3.2%), Native American (1.6%), other ethnicity (1.2%), and Asian (0.4%). One respondent (0.4%) did not indicate ethnicity. With regard to education attainment, 19 (7.6%) had not finished high school, 73 (29.1%) had only a high school diploma, 74 (29.5%) had attended college but had no degree, 12 (4.8%) had earned a 2-year degree, 31 (12.4%) had earned a 4-year degree, and 39 (15.5%) had earned a graduate degree. Three respondents (1.2%) did not indicate their educational attainment. Following an explanation of the research project and the signing of consent forms, each participant completed a survey booklet that explored demographic information and contained 2 measures of BPD: (1) the BPD scale of the Personality Diagnostic Questionnaire-412 (PDQ-4) and (2) the Self-Harm Inventory (SHI).13 Survey booklets were then placed in sealed envelopes and stored, pending analysis. This project was approved by the institutional review boards of the participating hospital and the local university. Results. Using the traditional cutoff scores of 5 for each meaure, 15 individuals (6.0%) scored positively on the PDQ-4 and 12 (4.8%) scored positively on the SHI; 5 (2.0%) scored positively on both measures, whereas 22 (8.8%) scored positively on either one measure or the other. In comparing the demographic profiles between those respondents who scored positively on either measure versus those respondents who scored negatively on both measures, there were no differences with regard to sex (χ2 = 0.58, P < .51). Similarly, there were no between-group differences in comparing white respondents to respondents of any other race (χ2 = 2.09, P < .15) or respondents with no more than a high school education to those with at least some college education (χ2 = 0.01, P < .95). However, those who scored positively on either measure of BPD were younger (mean = 48.77 years, SD = 13.01) on average compared to those who scored negatively on both measures of BPD (mean = 58.91 years, SD = 13.66) (F1,248 = 11.14, P < .001). How do the preceding rates in this study compare with general community rates? While the DSM-IV-TR states that the prevalence of BPD in the general population is 2%, Grant et al,14 in the National Epidemiologic Survey on Alcohol and Related Conditions, found a prevalence rate for BPD of 5.9%. With the exception of the percentage of respondents who were positive on either one measure or the other (but not both), all remaining prevalence findings in this study are at or below the recent US community prevalence rate determined by Grant et al.14 In other words, we did not find elevated rates of BPD in this sample of patients undergoing cardiac stress testing. A number of factors may explain these findings. First, individuals with BPD may gravitate away from disorders with definitive diagnoses (ie, cardiac disease). Second, the higher socioeconomic level of the studys geographic area may have precluded lower-functioning individuals with BPD. Third, referring clinicians and participating cardiologists may have deferred for cardiac stress testing those individuals with somatic features. Fourth, BPD measures with symptom criteria that are based on studies in younger populations (eg, self-cutting) may have underdetected symptoms in an older population. This is the first study to examine the prevalence of BPD in a population undergoing cardiac stress testing. Findings are potentially limited by the use of self-report measures for BPD. However, self-report measures run the risk of being overinclusive, and the prevalence rates for BPD in this study generally did not exceed general population norms. In addition, we used 2 measures of BPD, obtained a consecutive sample, and captured a reasonable sample size of patients. According to these findings, BPD is not overrepresented among patients who are referred for cardiac stress testing.

The prevalence of self-harm behaviors in a consecutive sample of cardiac stress test patients.

While self-harm behavior has been studied in various psychiatric populations, particularly the behaviors of suicide attempts and completions, little empirical data exists on the lifetime prevalence of various self-harm behaviors in non-psychiatric populations. In the present study, using a cross-sectional approach and a self-report survey methodology, we examined the lifetime prevalence of 22 self-harm behaviors in a consecutive sample of 250 patients undergoing cardiac stress testing. Results indicated that abuse alcohol was most common (17.2%) followed by promiscuity (10.4%); 6% reported a previous suicide atatempt. Findings indicate areas of clinician inquiry for self-harm behaviors in non-psychiatric patients.

Prevalence and self-reported medical history of overweight in a cardiac stress testing population.

Objectives: To determine the prevalence of overweight in a cardiac stress testing population, and the percentage of subjects who indicate a history of overweight. Methods: A total of 251 consecutive subjects presenting for cardiac stress testing in a 450-bed community hospital from June to September 2010 were asked to complete a survey booklet. The survey included all patients presenting for stress testing, regardless of indication. Participants were subjects, ages 18 or older, and male or female. Exclusion criteria were medical (eg, pain), psychiatric (eg, psychosis), or intellectual disturbances that would preclude the successful completion of a survey booklet. Results: Of the 251 participants 76.5% were overweight (BMI ≥25). Among the overweight participants, only 16.1% indicated a history of overweight. Conclusions: A high prevalence of overweight/obese individuals exists in a cardiac stress test population. A majority of overweight and obese patients did not indicate a history of overweight. These results indicate poor patient recognition and/or ineffective physician-to-patient education concerning unhealthy body weight. Greater and more effective efforts are needed to effectively educate patients about this modifiable risk factor for a myriad of health problems.