Lawrence J. Appel

State of the Science Promoting Self-Care in Persons With Heart Failure: A Scientific Statement From the American Heart Association

Self-care is advocated as a method of improving outcomes from heart failure (HF), the final common pathway for several prevalent illnesses, including hypertension and coronary artery disease. HF is widespread in aging populations across the world.1 The burden of HF is manifested in poor quality of life (QOL)2,3 and early mortality.4 In addition, there are >3 million ambulatory care and emergency department visits5 and well over 1 million hospitalizations for HF in the United States annually,6 which contributes to the exorbitant costs associated with HF. Much of this healthcare utilization is thought to be preventable if patients engage in consistent self-care.7,8 This scientific statement seeks to highlight concepts and evidence important to the understanding and promotion of self-care in persons with HF. Specifically, the document describes what is known about (1) the self-care behaviors required of HF patients, (2) factors that make self-care challenging for patients, (3) interventions that promote self-care, and (4) the effect of self-care on HF outcomes. The review ends with evidence-based recommendations for clinicians and direction for future research. Self-care is defined as a naturalistic decision-making process that patients use in the choice of behaviors that maintain physiological stability (symptom monitoring and treatment adherence) and the response to symptoms when they occur.9 The term naturalistic decision making is used to describe how people make decisions in real-world settings. Naturalistic decision makers focus on process rather than outcomes, make decisions based on the situation, let the context influence their decision-making processes, and base practical decisions on the information available at the moment.10 In HF, self-care maintenance requires following the advice of providers to take medications, eat a low-sodium diet, exercise, engage in preventive behaviors, and actively monitor themselves for signs and symptoms. Self-care management refers to decision making in …

Omega-3 Fatty Acids and Cardiovascular Disease New Recommendations From the American Heart Association

Since the original American Heart Association (AHA) Science Advisory was published in 1996,1 important new findings have been reported about the benefits of omega-3 fatty acids on cardiovascular disease (CVD). Omega-3 fatty acids are obtained from two dietary sources: seafood and certain nut and plant oils. Fish and fish oils contain the 20-carbon eicosapentaenoic acid (EPA) and the 22-carbon docosahexaenoic acid (DHA), whereas canola, walnut, soybean, and flaxseed oils contain the 18-carbon α-linolenic acid (ALA). ALA appears to be less potent than EPA and DHA. The evidence supporting the clinical benefits of omega-3 fatty acids derive from population studies and randomized, controlled trials, and new information has emerged regarding the mechanisms of action of these nutrients. These are outlined in a recent Scientific Statement, “Fish Consumption, Fish Oil, Omega-3 Fatty Acids and Cardiovascular Disease.”2 See page e20 Large-scale epidemiologic studies suggest that people at risk for coronary heart disease (CHD) benefit from consuming omega-3 fatty acids from plants and marine sources. Although the ideal amount to take is not firmly established, evidence from prospective secondary prevention studies suggests that intakes of EPA+DHA ranging from 0.5 …

Summary of the Scientific Conference on Dietary Fatty Acids and Cardiovascular Health Conference Summary From the Nutrition Committee of the American Heart Association

The objective of this Executive Summary is to provide a synopsis of the research findings presented at the American Heart Association conference “Dietary Fatty Acids and Cardiovascular Health—Dietary Recommendations for Fatty Acids: Is There Ample Evidence?” held on June 5–6, 2000, in Reston, Va. The conference was held to summarize the current understanding of the effects of fatty acids on risk of cardiovascular disease (CVD) and cancer, as well as to identify gaps in our knowledge base that need to be addressed. There is great interest in learning more about the biological effects of the individual fatty acids, their role in chronic disease risk, and their underlying mechanisms of action. As research advances are made, there is always the need to question how new findings may be translated into practice. There is a long history of research providing the basis for the modification of existing dietary guidelines. Research findings have been used to verify intake criteria and are considered along with practical issues of implementation to establish new guidelines. A substantive body of consistent evidence sufficient to defend a dietary recommendation or a change in existing dietary guidance is essential. The conference highlighted the progress that has been made in understanding the biological effects of fatty acids and also addressed the need to learn more about how different fatty acids affect the risk of chronic disease, within the context of refining dietary guidance to further enhance health. As study designs have become increasingly rigorous, a number of megatrends have emerged from the data.1 2 There is increased emphasis on identifying the type of fat that best correlates with disease end points. The classic studies of Keys et al3 and Hegsted et al4 have shown that saturated fatty acids (ie, those with a carbon chain length of C12:0 …

Comparison of Two ELISA Methods and Mass Spectrometry for Measurement of Vitamin D‐Binding Protein: Implications for the Assessment of Bioavailable Vitamin D Concentrations Across Genotypes

Studies using vitamin D‐binding protein (DBP) concentrations to estimate free and bioavailable vitamin D have increased dramatically in recent years. Combinations of two single‐nucleotide polymorphisms (SNPs) produce three major DBP isoforms (Gc1f, Gc1s, and Gc2). A recent study showed that DBP concentrations quantified by liquid chromatography–tandem mass spectrometry (LC‐MS/MS) did not differ by race, whereas a widely used monoclonal enzyme‐linked immunosorbent assay (ELISA) quantified DBP differentially by isoform, yielding significantly lower DBP concentrations in black versus white individuals. We compared measurements of serum DBP using a monoclonal ELISA, a polyclonal ELISA, and LC‐MS/MS in 125 participants in the Chronic Renal Insufficiency Cohort (CRIC). Serum free and bioavailable 25OHD were calculated based on DBP concentrations from these three assays in homozygous participants, and race differences were compared. We confirmed that the monoclonal ELISA quantifies DBP differentially by isoform and showed that the polyclonal ELISA is not subject to this bias. Whereas ≤9% of the variability in DBP concentrations quantified using either LC‐MS/MS or the polyclonal ELISA was explained by genotype, 85% of the variability in the monoclonal ELISA‐based measures was explained by genotype. DBP concentrations measured by the monoclonal ELISA were disproportionately lower than LC‐MS/MS‐based results for Gc1f homozygotes (median difference –67%; interquartile range [IQR] –71%, –64%), 95% of whom were black. In contrast, the polyclonal ELISA yielded consistently and similarly higher measurements of DBP than LC‐MS/MS, irrespective of genotype, with a median percent difference of +50% (IQR +33%, +65%). Contrary to findings using the monoclonal ELISA, DBP concentrations did not differ by race, and free and bioavailable 25OHD were significantly lower in black versus white participants based on both the polyclonal ELISA and LC‐MS/MS, consistent with their lower total 25OHD. Future studies of DBP and free or bioavailable vitamin D metabolites should employ DBP assays that are not biased by DBP genotype.

Design considerations and rationale of a multi-center trial to sustain weight loss: the weight loss maintenance trial

Background The Weight Loss Maintenance Trial (WLM) is a multi-center, randomized, controlled trial that compares the effects of two 30-month maintenance interventions, i.e., Personal Contact (PC) and Interactive Technology (IT) to a self-directed usual care control group (SD), in overweight or obese individuals who are at high risk for cardiovascular disease. Purpose This paper provides an overview of the design and methods, and design considerations and lessons learned from this trial. Methods All participants received a 6-month behavioral weight loss program consisting of weekly group sessions. Participants who lost 4 kg were randomized to one of three conditions (PC, IT, or SD). The PC condition provided monthly contacts with an interventionist primarily via telephone and quarterly face-to-face visits. The IT condition provided frequent, individualized contact through a tailored, website system. Both the PC and IT maintenance programs encouraged the DASH dietary pattern and employed theory-based behavioral techniques to promote maintenance. Results Design considerations included choice of study population, frequency and type of intervention visits, and choice of primary outcome. Overweight or obese persons with CVD risk factors were studied. The pros and cons of studying this population while excluding others are presented. We studied intervention contact strategies that made fewer demands on participant time and travel, while providing frequent opportunities for interaction. The primary outcome variable for the trial was change in weight from randomization to end of follow-up (30 months). Limitations Limits to generalizability are discussed. Individuals in need of weight loss strategies may have been excluded due to barriers associated with internet use. Other participants may have been excluded secondary to a comorbid condition. Conclusions This paper highlights the design and methods of WLM and informs readers of discussions of critical issues and lessons learned from the trial. Clinical Trials 2008; 5: 546—556. http://ctj.sagepub.com

Comprehensive lifestyle modification and blood pressure control: A review of the PREMIER trial

The PREMIER trial assessed the aggregate effect on blood pressure (BP) of nationally recommended lifestyle modifications in free‐living adults with high‐normal (stage 1) hypertension. Participants (N=810) were randomized to the advice‐only group; the established group (consisting of weight loss, increased physical activity, and reduced sodium and alcohol intake); or the established plus Dietary Approaches to Stop Hypertension (DASH) diet group (consisting of the established interventions in addition to the DASH dietary pattern). The primary outcome was change in systolic BP at 6 months. Net of advice only, mean systolic BP declined by 3.7 mm Hg for members of the established group (p<0.001) and 4.3 mm Hg for the established plus DASH group (p<0.001). The prevalence of hypertension decreased from a baseline of 38% to 17% in the established group (p=0.01) and to 12% in the established plus DASH group (p<0.001) compared with a decrease to 26% in the advice‐only group. The PREMIER trial demonstrated that persons with above‐optimal BP and stage 1 hypertension can make multiple lifestyle changes leading to better control of BP.

Short report : the effect of fish oil on blood pressure and high-density lipoprotein-cholesterol levels in phase I of the trials of hypertension prevention

Objective To study the effects of moderate doses of fish oil on blood pressure and high-density lipoprotein (HDL)-cholesterol. Methods The participants were 350 normotensive men and women aged 30–54 years who were enrolled from seven academic medical centers in phase I of the Trials of Hypertension Prevention. They were randomly assigned to receive placebo or 6g purified fish oil once a day, which supplied 3g n-3 polyunsaturated fatty acids for 6 months. Results Baseline blood pressure was (mean ± SD) 123±9/81 ±5mmHg. The mean differences in the blood pressure changes between the fish oil and placebo groups were not statistically significant. There was no tendency for fish oil to reduce blood pressure more in subjects with baseline blood pressures in the upper versus the lower quartile (132/87 versus 114/75 mmHg), low habitual fish consumption (0.4 versus 2.9 times a week) or low baseline plasma levels of n-3 fatty acids. Fish oil increased HDL2-cholesterol significantly compared with the placebo group. Subgroup analysis showed this effect to be significant in the women but not in the men. Increases in serum phospholipid n-3 fatty acids were significantly correlated with increases in HDL2-cholesterol and decreases in systolic blood pressure. Conclusion Moderate amounts of fish oil (6g/day) are unlikely to lower blood pressure in normotensive persons, but may increase HDL2-cholesterol, particularly in women.

Effect of age on the efficacy of blood pressure treatment strategies.

To study whether the proportion of excess cardiovascular events attributable to various levels of systolic blood pressure varies with age, we calculated the population-attributable risk of all-cause mortality, fatal and nonfatal cardiovascular events (stroke, coronary heart disease, angina, congestive heart failure, and peripheral vascular disease), and stroke incidence due to systolic blood pressure in men and women 45 years of age or older in the United States during 1980. Our estimates are based on US census counts, blood pressure prevalence distributions from the second National Health and Nutrition Examination Survey, and the annual risk of cardiovascular complications during 18 years of follow-up in the Framingham cohort We then determined the impact of age on the relative efficacy of mass treatment and case-finding strategies in preventing systolic blood pressure-related events. At 45–54 years of age, only 30–40% of systolic blood pressure-related excess events occur in hypertensive individuals (systolic blood pressure ≥160 mm Hg). With increasing age, however, the percentage of systolic blood pressure-related events that occur in hypertensive individuals rose substantially, in the oldest age group (≥75 years), 65–70% of fatal and nonfatal cardiovascular disease events occur in hypertensive persons. The pattern is similar for men and women. The potential impact of a mass treatment strategy designed to shift the distribution of blood pressure downward by a small amount is greater in younger than in older groups, whereas an opposite trend is seen for a high-risk, hypertensive case-finding and treatment approach. In every age, a combined mass and high-risk treatment strategy is superior to either strategy alone. Our analysis suggests that the age of the target population should be considered when designing interventions to prevent blood pressure-related cardiovascular disease

Stakeholder Discussion to Reduce Population-Wide Sodium Intake and Decrease Sodium in the Food Supply A Conference Report From the American Heart Association Sodium Conference 2013 Planning Group

Background— A 2-day interactive forum was convened to discuss the current status and future implications of reducing sodium in the food supply and to identify opportunities for stakeholder collaboration. Methods and Results— Participants included 128 stakeholders engaged in food research and development, food manufacturing and retail, restaurant and food service operations, regulatory and legislative activities, public health initiatives, healthcare, academia and scientific research, and data monitoring and surveillance. Presentation topics included scientific evidence for sodium reduction and public health policy recommendations; consumer sodium intakes, attitudes, and behaviors; food technologies and solutions for sodium reduction and sensory implications; experiences of the food and dining industries; and translation and implementation of sodium intake recommendations. Facilitated breakout sessions were conducted to allow for sharing of current practices, insights, and expertise. Conclusions— A well-established body of scientific research shows that there is a strong relationship between excess sodium intake and high blood pressure and other adverse health outcomes. With Americans getting >75% of their sodium from processed and restaurant food, this evidence creates mounting pressure for less sodium in the food supply. The reduction of sodium in the food supply is a complex issue that involves multiple stakeholders. The success of new technological approaches for reducing sodium will depend on product availability, health effects (both intended and unintended), research and development investments, quality and taste of reformulated foods, supply chain management, operational modifications, consumer acceptance, and cost. The conference facilitated an exchange of ideas and set the stage for potential collaboration opportunities among stakeholders with mutual interest in reducing sodium in the food supply and in Americans’ diets. Population-wide sodium reduction remains a critically important component of public health efforts to promote cardiovascular health and prevent cardiovascular disease and will remain a priority for the American Heart Association.

Risk Factors for Peripheral Arterial Disease Among Patients With Chronic Kidney Disease

Patients with chronic kidney disease (CKD) have an increased risk for developing peripheral arterial disease (PAD). The aim of this study was to examine the cross-sectional association between novel risk factors and prevalent PAD in patients with CKD. A total of 3,758 patients with estimated glomerular filtration rates of 20 to 70 ml/min/1.73 m(2) who participated in the Chronic Renal Insufficiency Cohort (CRIC) study were included in the present analysis. PAD was defined as an ankle-brachial index <0.9 or a history of arm or leg revascularization. After adjustment for age, gender, race, cigarette smoking, physical activity, history of hypertension and diabetes, pulse pressure, high-density lipoprotein cholesterol, estimated glomerular filtration rate, and CRIC clinical sites, several novel risk factors were significantly associated with PAD. For example, odds ratios for a 1-SD higher level of risk factors were 1.18 (95% confidence interval [CI] 1.08 to 1.29) for log-transformed high-sensitivity C-reactive protein, 1.18 (95% CI 1.08 to 1.29) for white blood cell count, 1.15 (95% CI 1.05 to 1.25) for fibrinogen, 1.13 (95% CI 1.03 to 1.24) for uric acid, 1.14 (95% CI 1.02 to 1.26) for glycosylated hemoglobin, 1.11 (95% CI 1.00 to 1.23) for log-transformed homeostasis model assessment of insulin resistance, and 1.35 (95% CI 1.18 to 1.55) for cystatin C. In conclusion, these data indicate that inflammation, prothrombotic state, oxidative stress, insulin resistance, and cystatin C were associated with an increased prevalence of PAD in patients with CKD. Further studies are warranted to examine the causal effect of these risk factors on PAD in patients with CKD.