Kathleen T. Hickey

Effect of β-blocking therapy on outcome in the Multicenter UnSustained Tachycardia Trial (MUSTT)

Background—&bgr;-Blockers are known to reduce total mortality and sudden death in survivors of recent myocardial infarction. The effects of these agents in patients at high risk for sudden death with remote infarction are not clear. Methods and Results—We analyzed the effect of &bgr;-blockers on outcomes in 2096 patients with coronary artery disease, ejection fraction ≤40%, and spontaneous nonsustained ventricular tachycardia enrolled in the Multicenter UnSustained Tachycardia Trial (MUSTT). Forty-five percent of 702 patients with inducible sustained ventricular tachyarrhythmia and 35% of 1394 patients without inducible tachycardia were discharged from hospital receiving &bgr;-blockers. Patients treated with &bgr;-blockers were younger and had higher ejection fractions, higher rates of recent angina, and more recent infarction. &bgr;-Blockers were associated with decreased total mortality for the entire study population (5-year mortality 50% with &bgr;-blockers versus 66% without &bgr;-blockers; adjusted P =0.0001). The mortality benefit associated with &bgr;-blockers was present in patients with and without inducible tachycardia, except those treated with implantable defibrillators. There was no significant effect of &bgr;-blocker therapy on the rate of arrhythmic death or cardiac arrest (adjusted P =0.2344). Conclusions—&bgr;-Blocking agents have beneficial effects on survival of patients having characteristics of those enrolled in the MUSTT trial. These effects do not appear to be due to a specific antiarrhythmic effect of &bgr;-blockers. The beneficial effects of &bgr;-blockers were demonstrable in all patients except those treated with implantable defibrillators.

Utility of positron emission tomography in predicting cardiac events and survival in patients with coronary artery disease and severe left ventricular dysfunction.

that many patients referred for transplantation can actually safely undergo coronary artery bypass grafting if they have viable myocardium identified with positron emission tomography (PET). The delineation of viable from nonviable myocardium is critically important, especially in patients with severe left ventricular (LV) dysfunction because they derive the most benefit from surgical interventions, but also have the highest perioperative risk. 4‐ 7 The purpose of this study was to determine the utility of PET in predicting cardiac events in patients with coronary artery disease and severe LV dysfunction and the outcome of these patients based on the choice of medical therapy or revascularization. ••• A retrospective analysis of all patients who had

Assessment of cardiac wall motion and ejection fraction with gated PET using N-13 ammonia

Background: Cardiac gating is not routinely used in cardiac positron emission tomography (PET). The aim of this study was to determine the feasibility of assessing regional wall motion, ejection fraction (EF), cardiac volumes, and mass with nitrogen-13 ammonia (N-13 ammonia) at the time of PET myocardial perfusion imaging. Methods: We studied 12 healthy volunteers (mean age, 28 ± 8 years) and 53 patients with documented coronary artery disease (CAD) (mean age, 59 ± 11 years). All subjects received a single administration of approximately 600 MBq (16 mCi) of N-13 ammonia intravenously. A 6-minute dynamic scan was performed for quantitative assessment of myocardial perfusion at rest, followed by a separate, 13-minute static scan acquired in the gated mode (8 equal bins). Gated data was imported into the Emory Toolbox. Wall motion was evaluated by dividing the myocardium into 9 anatomic regions graded semiquantitatively. Results: Healthy volunteers had a normal EF (61 ± 6), end systolic volume (ESV) (37 ± 15 mL), end diastolic volume (EDV) (89 ± 25 mL), and cardiac mass (116 ± 18 g). In contrast, patients with CAD showed reduced EF (32 ± 13%) and increased ESV (129 ± 56 mL), EDV (188 ± 68 mL), and cardiac mass (173 ± 45g) (P < 0.001 for each). In patients with CAD, EF measured by gated PET correlated significantly to independent measurements of EF (P < 0.001). Conclusions: Gating of cardiac perfusion images obtained after administration of N-13 ammonia is feasible and appears to be an accurate means of evaluating regional and global cardiac function. Gating can provide important additional diagnostic and prognostic information.

The Efficacy of Implantable Cardioverter-Defibrillators in Heart Transplant RecipientsCLINICAL PERSPECTIVE

Background—Sudden cardiac death among orthotopic heart transplant recipients is an important mechanism of death after cardiac transplantation. The role for implantable cardioverter-defibrillators (ICDs) in this population is not well established. This study sought to determine whether ICDs are effective in preventing Sudden cardiac death in high-risk heart transplant recipients. Methods and Results—We retrospectively analyzed the records of all orthotopic heart transplant patients who had ICD implantation between January 1995 and December 2005 at 5 heart transplant centers. Thirty-six patients were considered high risk for sudden cardiac death. The mean age at orthotopic heart transplant was 44±14 years, the majority being male (n=29). The mean age at ICD implantation was 52±14 years, whereas the average time from orthotopic heart transplant to ICD implant was 8 years ±6 years. The main indications for ICD implantation were severe allograft vasculopathy (n=12), unexplained syncope (n=9), history of cardiac arrest (n=8), and severe left ventricular dysfunction (n=7). Twenty-two shocks were delivered to 10 patients (28%), of whom 8 (80%) received 12 appropriate shocks for either rapid ventricular tachycardia or ventricular fibrillation. The shocks were effective in terminating the ventricular arrhythmias in all cases. Three (8%) patients received 10 inappropriate shocks. Underlying allograft vasculopathy was present in 100% (8 of 8) of patients who received appropriate ICD therapy. Conclusions—Use of ICDs after heart transplantation may be appropriate in selected high-risk patients. Further studies are needed to establish an appropriate prevention strategy in this population.

The Efficacy of Implantable Cardioverter-Defibrillators in Heart Transplant Recipients: Results from a Multicenter Registry

Background—Sudden cardiac death among orthotopic heart transplant recipients is an important mechanism of death after cardiac transplantation. The role for implantable cardioverter-defibrillators (ICDs) in this population is not well established. This study sought to determine whether ICDs are effective in preventing Sudden cardiac death in high-risk heart transplant recipients. Methods and Results—We retrospectively analyzed the records of all orthotopic heart transplant patients who had ICD implantation between January 1995 and December 2005 at 5 heart transplant centers. Thirty-six patients were considered high risk for sudden cardiac death. The mean age at orthotopic heart transplant was 44±14 years, the majority being male (n=29). The mean age at ICD implantation was 52±14 years, whereas the average time from orthotopic heart transplant to ICD implant was 8 years ±6 years. The main indications for ICD implantation were severe allograft vasculopathy (n=12), unexplained syncope (n=9), history of cardiac arrest (n=8), and severe left ventricular dysfunction (n=7). Twenty-two shocks were delivered to 10 patients (28%), of whom 8 (80%) received 12 appropriate shocks for either rapid ventricular tachycardia or ventricular fibrillation. The shocks were effective in terminating the ventricular arrhythmias in all cases. Three (8%) patients received 10 inappropriate shocks. Underlying allograft vasculopathy was present in 100% (8 of 8) of patients who received appropriate ICD therapy. Conclusions—Use of ICDs after heart transplantation may be appropriate in selected high-risk patients. Further studies are needed to establish an appropriate prevention strategy in this population.

Refocusing Research Priorities in Schools of Nursing

It is critical for schools of nursing to periodically reassess their scholarly programs to ensure that their conceptual framework and approaches address current challenges and enhance productivity. This article describes the process undertaken at Columbia University School of Nursing to evaluate scholarly enterprise so that it remains relevant and responsive to changing trends and to revise our research conceptual model to be reflective of the foci of our clinicians and researchers. As part of a larger strategic initiative, a two-phase Research Excellence Planning and Implementation Workgroup was convened, consisting of a broad representation of faculty and administrative staff, with an overall goal of expanding scholarly capacity. During Phase I, members developed measurable outcomes and tactics and revised the schools conceptual research model. In Phase II, the workgroup implemented and monitored tactics and presented final recommendations to the dean. To measure progress, faculty members completed a survey to establish baseline scholarship and collaboration with results indicating room for growth in interdisciplinary and inter-institutional collaboration. Ongoing assessment of outcomes includes Web-based tracking of scholarly activities and follow-up surveys to monitor expansion of faculty collaboration. We recommend this process to other schools committed to sustainable, increasingly relevant scholarship.

Focal Left Atrial Tachycardias Not Associated with Prior Catheter Ablation for Atrial Fibrillation: Clinical and Electrophysiological Characteristics

Background:  The clinical features and electrophysiological characteristics of patients with focal left atrial tachycardias (LATs) are not well characterized. This study reports the experience of a single center in catheter mapping and radiofrequency ablation of focal LAT not associated with prior atrial fibrillation (AF) ablation, including in cardiac sarcoidosis and transplant patients.

Cardiovascular Genomics: Cardiovascular Genomics

PURPOSE This article provides an update on cardiovascular genomics using three clinically relevant exemplars, including myocardial infarction (MI) and coronary artery disease (CAD), stroke, and sudden cardiac death (SCD). ORGANIZATIONAL CONSTRUCT: Recent advances in cardiovascular genomic research, testing, and clinical implications are presented. METHODS Genomic nurse experts reviewed and summarized recent salient literature to provide updates on three selected cardiovascular genomic conditions. FINDINGS Research is ongoing to discover comprehensive genetic markers contributing to many common forms of cardiovascular disease (CVD), including MI and stroke. However, genomic technologies are increasingly being used clinically, particularly in patients with long QT syndrome (LQTS) or hypertrophic cardiomyopathy (HCM) who are at risk for SCD. CONCLUSIONS Currently, there are no clinically recommended genetic tests for many common forms of CVD even though direct-to-consumer genetic tests are being marketed to healthcare providers and the general public. On the other hand, genetic testing for patients with certain single gene conditions, including channelopathies (e.g., LQTS) and cardiomyopathies (e.g., HCM), is recommended clinically. CLINICAL RELEVANCE Nurses play a pivotal role in cardiogenetics and are actively engaged in direct clinical care of patients and families with a wide variety of heritable conditions. It is important for nurses to understand current development of cardiovascular genomics and be prepared to translate the new genomic knowledge into practice.

Advanced nursing practice and research contributions to precision medicine.

BACKGROUND Genomic discoveries in the era of precision medicine hold the promise for tailoring healthcare, symptom management, and research efforts including targeting rare and common diseases through the identification and implementation of genomic-based risk assessment, treatment, and management. However, the translation of these discoveries into tangible benefits for the health of individuals, families, and the public is evolving. PURPOSE In this article, members of the Genetics Expert Panel identify opportunities for action to increase advanced practice nursing and research contributions toward improving genomic health for all individuals and populations. DISCUSSION Identified opportunities are within the areas of: bolstering genomic focused advanced practice registered nurse practice, research and education efforts; deriving new knowledge about disease biology, risk assessment, treatment efficacy, drug safety and self-management; improving resources and systems that combine genomic information with other healthcare data; and advocating for patient and family benefits and equitable access to genomic healthcare resources.

Initial evaluation of the Robert Wood Johnson Foundation Nurse Faculty Scholars program

BACKGROUND The Robert Wood Johnson Foundation Nurse Faculty Scholars (RWJF NFS) program was developed to enhance the career trajectory of young nursing faculty and to train the next generation of nurse scholars. Although there are publications that describe the RWJF NFS, no evaluative reports have been published. The purpose of this study was to evaluate the first three cohorts (n = 42 scholars) of the RWJF NFS program. METHODS A descriptive research design was used. Data were derived from quarterly and annual reports, and a questionnaire (seven open-ended questions) was administered via Survey Monkey Inc. (Palo Alto, CA, USA). RESULTS During their tenure, scholars had on average six to seven articles published, were teaching/mentoring at the graduate level (93%), and holding leadership positions at their academic institutions (100%). Eleven scholars (26%) achieved fellowship in the American Academy of Nursing, one of the highest nursing honors. The average ratings on a Likert scale of 1 (not at all supportive) to 10 (extremely supportive) of whether or not RWJF had helped scholars achieve their goals in teaching, service, research, and leadership were 7.7, 8.0, 9.4, and 9.5, respectively. The majority of scholars reported a positive, supportive relationship with their primary nursing and research mentors; although, several scholars noted challenges in connecting for meetings or telephone calls with their national nursing mentors. CONCLUSIONS These initial results of the RWJF NFS program highlight the success of the program in meeting its overall goal-preparing the next generation of nursing academic scholars for leadership in the profession.