Mariann R. Piano

Team Management of Patients With Heart Failure A Statement for Healthcare Professionals From the Cardiovascular Nursing Council of the American Heart Association

Heart failure is estimated to affect 4 to 5 million Americans, with 550 000 new cases reported annually.1 In the past 3 decades, both the incidence and prevalence of heart failure have increased.1 2 3 Factors that have contributed to this increase are the aging US population and improved survival rates in patients with cardiovascular disease due to advancements in diagnostic techniques and medical and surgical therapies.2 4 5 6 Heart failure is a chronic, progressive disease that is characterized by frequent hospital admissions and ultimately high mortality rates. Because of its high medical resource consumption, heart failure is the most costly cardiovascular illness in the United States.7 Advances in the treatment of heart failure and early intervention to prevent decompensation may delay disease progression and improve survival. After initial evaluation, further diagnostic testing, and implementation of standard medical therapy, outpatient management strategies focus on maintenance of patient stability. Patient counseling/education, promotion of compliance, and discharge planning may further contribute to clinical stability and improved patient outcomes. A variety of outpatient heart failure management programs have been implemented during the past decade. These programs may also contribute to improved heart failure patient outcomes, including decreased symptoms, improved quality of life, reduced rates of hospital admission, and decreased healthcare costs. The purpose of the present report was to examine current heart failure management strategies and programs and to provide recommendations regarding (1) the use of an integrated approach to care through systematic assessment and management, (2) counseling and education of patients, (3) promotion of patient compliance with the treatment regimen, and (4) facilitation of hospital discharge/implementation of outpatient models of healthcare delivery. ### Pathophysiology and Definition of Heart Failure The syndrome of heart failure is a result of complex interactions among molecular, endocrine, and biodynamic systems. There are several pathophysiological mechanisms that are involved …

Wine and Your Heart A Science Advisory for Healthcare Professionals From the Nutrition Committee, Council on Epidemiology and Prevention, and Council on Cardiovascular Nursing of the American Heart Association

Data regarding the incidence of coronary heart disease (CHD) in different populations have generated a series of hypotheses that protective substances in the diet may counteract the harmful effects of high-cholesterol, high-saturated-fat diets. One such potential food substance is wine, especially red wine. The purpose of this advisory is to summarize the current literature on wine intake and cardiovascular disease. As stated in a previous advisory on alcohol and CHD,1 recommendations for use of a nonessential dietary component with significant health hazards require definitive evidence of benefit. Although population surveys and in vitro experiments show that wine may have limited beneficial effects, more compelling data exist for other less-hazardous approaches to cardiovascular risk reduction. ### Do Epidemiological Data Support a Role for Alcoholic Beverages (Wine in Particular) as a Cardioprotective Substance? There are more than 60 prospective studies that suggest an inverse relation between moderate alcoholic beverage consumption and CHD.2 A consistent coronary protective effect has been observed for consumption of 1 to 2 drinks per day of an alcohol-containing beverage; however, higher intakes are associated with increased total mortality.3 4 Although ecological studies support an association between wine intake and lower CHD risk, these studies are confounded by lifestyle, diet, and other cultural factors.4 5 6 7 Most cohort studies do not support an association between type of alcoholic beverage and prevention of heart disease; however, a few have suggested that wine may be more beneficial than beer or spirits.8 9 It remains unclear whether red wine confers any advantage over white wine or other types of alcoholic beverages. A synthesis of the observational studies is difficult because of wide variations in methodology, measurement error in alcohol consumption, and biological variability in response to alcohol consumption (which tends to underestimate effect). Moreover, consumption may vary over time, and this is often not taken into consideration in observational studies. Consumption of alcohol …

Electronic Cigarettes A Policy Statement From the American Heart Association

For decades, advocacy for tobacco control has been a priority of the American Heart Association (AHA). In partnership with major public health organizations, the association has made major strides in tobacco use prevention and cessation by prioritizing evidence-based strategies such as increasing excise taxes; passing comprehensive smoke-free air laws; facilitating US Food and Drug Administration (FDA) authority to regulate tobacco, including comprehensive tobacco cessation treatment within healthcare plans; and supporting adequate funding of comprehensive tobacco control programs in different states. These tobacco control efforts have cut in half the youth smoking rate from 1997 to 2007 and have saved >8 million lives in the past 50 years.1 However, the work is far from done and has stalled, especially for people living below the poverty line, those with mental illnesses,2 and those with low educational attainment.3 Unless current trends reverse, ≈5.6 million children alive today in the United States will die prematurely of smoking-related diseases.1 Even now, cigarette smoking kills nearly half a million Americans each year, and an additional 16 million individuals suffer from smoking-related illness, which costs the United States

Impact of Smokeless Tobacco Products on Cardiovascular Disease: Implications for Policy, Prevention, and Treatment A Policy Statement From the American Heart Association

289 billion dollars annually in direct medical care and other economic costs.1 This statement reviews the latest science concerning one of the newest classes of products to enter the tobacco product landscape—electronic cigarettes (e-cigarettes), also called electronic nicotine delivery systems (ENDS)—and provides an overview on design, operations, constituents, toxicology, safety, user profiles, public health, youth access, impact as a cessation aid, and secondhand exposure. On the basis of the current evidence, we provide policy recommendations in key areas of tobacco control such as clean indoor air laws, taxation, regulation, preventing youth access, marketing and advertising to youth, counseling for cessation, surveillance, and defining e-cigarettes in state laws. The statement concludes by outlining a future …

Wine and Your Heart: A Science Advisory for Healthcare Professionals From the Nutrition Committee, Council on Epidemiology and Prevention, and Council on Cardiovascular Nursing of the American Heart Association

Various forms of smokeless tobacco (ST) products (snuff, chewing tobacco) are used by individuals of all ages. Over the past several years, US tobacco companies have expanded marketing and promotion of ST products. A major aim of this statement is to review and summarize the scientific evidence regarding ST product use and the potential cardiovascular risks associated with ST product use that can be used to inform policy related to tobacco control and strategies related to tobacco harm reduction. A specific policy question is whether ST products should be recommended to smokers instead of cigarettes to reduce the morbidity and mortality associated with smoking and/or as an approach to enhance smoking cessation. Although evidence is consistent with the suggestion that the cardiovascular risks are lower with ST products compared with cigarette smoking, ST products are not without harm. As reviewed in this statement, there is evidence that long-term ST product use may be associated with a modest risk of fatal myocardial infarction (MI) and fatal stroke, suggesting that ST product use may complicate or reduce the chance for survival after a MI or stroke. In addition, there is inadequate evidence to support the use of ST products as a smoking cessation strategy. Based on the findings reviewed in this statement, clinicians should continue to discourage use of all tobacco products and emphasize prevention of smoking initiation and smoking cessation as primary goals for tobacco control. In the United States, various forms of ST products (snuff, chewing tobacco) are used by individuals of all ages, including adolescents and young adults.1 Over the past several years, US cigarette companies have been purchasing companies that only previously sold ST products.2 Consequently, there has been a proliferation of ST products such as moist snuff and snus that are sold under cigarette brand …

Alcoholic cardiomyopathy: pathophysiologic insights.

Data regarding the incidence of coronary heart disease (CHD) in different populations have generated a series of hypotheses that protective substances in the diet may counteract the harmful effects of high-cholesterol, high-saturated-fat diets. One such potential food substance is wine, especially red wine. The purpose of this advisory is to summarize the current literature on wine intake and cardiovascular disease. As stated in a previous advisory on alcohol and CHD,1 recommendations for use of a nonessential dietary component with significant health hazards require definitive evidence of benefit. Although population surveys and in vitro experiments show that wine may have limited beneficial effects, more compelling data exist for other less-hazardous approaches to cardiovascular risk reduction. ### Do Epidemiological Data Support a Role for Alcoholic Beverages (Wine in Particular) as a Cardioprotective Substance? There are more than 60 prospective studies that suggest an inverse relation between moderate alcoholic beverage consumption and CHD.2 A consistent coronary protective effect has been observed for consumption of 1 to 2 drinks per day of an alcohol-containing beverage; however, higher intakes are associated with increased total mortality.3 4 Although ecological studies support an association between wine intake and lower CHD risk, these studies are confounded by lifestyle, diet, and other cultural factors.4 5 6 7 Most cohort studies do not support an association between type of alcoholic beverage and prevention of heart disease; however, a few have suggested that wine may be more beneficial than beer or spirits.8 9 It remains unclear whether red wine confers any advantage over white wine or other types of alcoholic beverages. A synthesis of the observational studies is difficult because of wide variations in methodology, measurement error in alcohol consumption, and biological variability in response to alcohol consumption (which tends to underestimate effect). Moreover, consumption may vary over time, and this is often not taken into consideration in observational studies. Consumption of alcohol …Data regarding the incidence of coronary heart disease (CHD) in different populations have generated a series of hypotheses that protective substances in the diet may counteract the harmful effects of high-cholesterol, high-saturated-fat diets. One such potential food substance is wine, especially red wine. The purpose of this advisory is to summarize the current literature on wine intake and cardiovascular disease. As stated in a previous advisory on alcohol and CHD,1 recommendations for use of a nonessential dietary component with significant health hazards require definitive evidence of benefit. Although population surveys and in vitro experiments show that wine may have limited beneficial effects, more compelling data exist for other less-hazardous approaches to cardiovascular risk reduction. ### Do Epidemiological Data Support a Role for Alcoholic Beverages (Wine in Particular) as a Cardioprotective Substance? There are more than 60 prospective studies that suggest an inverse relation between moderate alcoholic beverage consumption and CHD.2 A consistent coronary protective effect has been observed for consumption of 1 to 2 drinks per day of an alcohol-containing beverage; however, higher intakes are associated with increased total mortality.3 4 Although ecological studies support an association between wine intake and lower CHD risk, these studies are confounded by lifestyle, diet, and other cultural factors.4 5 6 7 Most cohort studies do not support an association between type of alcoholic beverage and prevention of heart disease; however, a few have suggested that wine may be more beneficial than beer or spirits.8 9 It remains unclear whether red wine confers any advantage over white wine or other types of alcoholic beverages. A synthesis of the observational studies is difficult because of wide variations in methodology, measurement error in alcohol consumption, and biological variability in response to alcohol consumption (which tends to underestimate effect). Moreover, consumption may vary over time, and this is often not taken into consideration in observational studies. Consumption of alcohol …

Cigarette Smoke-induced Left Ventricular Remodelling is Associated with Activation of Mitogen-activated Protein Kinases

Alcoholic cardiomyopathy (ACM) is a specific heart muscle disease found in individuals with a history of long-term heavy alcohol consumption. ACM is associated with a number of adverse histological, cellular, and structural changes within the myocardium. Several mechanisms are implicated in mediating the adverse effects of ethanol, including the generation of oxidative stress, apoptotic cell death, impaired mitochondrial bioenergetics/stress, derangements in fatty acid metabolism and transport, and accelerated protein catabolism. In this review, we discuss the evidence for such mechanisms and present the potential importance of drinking patterns, genetic susceptibility, nutritional factors, race, and sex. The purpose of this review is to provide a mechanistic paradigm for future research in the area of ACM.

The molecular and cellular pathophysiology of heart failure

To determine the effects of cigarette smoke (CS) exposure on the expression/activation of mitogen‐activated protein kinases (MAPKs) (extracellular signal‐regulated kinase [ERK1/2], p38‐kinase [p38] and c‐Jun NH2‐terminal protein kinase [JNK]), norepinephrine (NE) and myocardial structure and function.

Sexual dimorphism in rat left atrial function and response to adrenergic stimulation.

In the United States, it is estimated that heart failure develops in 465,000 people each year. Heart failure occurs in both men and women and is associated with a high morbidity and mortality rate in both sexes and in all races. Our knowledge of the pathophysiology of heart failure has advanced beyond the cardiorenal-neurohumoral model and now includes changes in myocyte structure and function. Cellular changes in heart failure include myocyte hypertrophy, abnormalities in calcium homeostasis, excitation-contraction coupling, cross-bridge cycling, and changes in the cytoskeletal architecture. Data also indicate that some of these changes are found during the compensated stage of heart failure; whereas other changes are found during overt decompensation and are associated with changes in systolic and diastolic function. The transition from compensated to decompensated heart failure is more than likely related to the overexpression of neurohormones and peptides such as norepinephrine, angiotensin II, and proinflammatory cytokines. The purpose of this article is to review the epidemiology and cellular pathophysiology of heart failure.

The association of pain with protein inflammatory biomarkers: a review of the literature.

A number of investigations in humans and animals suggest that there may be intrinsic sex-associated differences in cardiac function. Using left atrial preparations from male and female rat hearts, we examined differences in myocardial function and response to adrenergic agonists. Contractile parameters were measured in isolated atria by conventional isometric methods in the absence or presence of isoproterenol or phenylephrine. Responsiveness to Ca2+ was measured in detergent-skinned atrial fibers and actomyosin ATPase activity was measured in isolated myofibrils. Tetanic contractions were generated by treating the atrium with ryanodine followed by high frequency stimulation. Developed force was greater and maximal rates of contraction and relaxation were more rapid in the female atrium. The relationship between Ca2+ concentration and force in both intact atria and detergent-skinned atrial fibers in females fell to the left of that for males. At low Ca2+ concentrations, skinned fibers from female atria generated more force and myofibrils from female atria had higher myosin ATPase activity than males. Tetanic contraction in the presence of high extracellular Ca2+ was greater in female atria. Male atrium had larger inotropic responses to isoproterenol and to phenylephrine, but drug-elicited cAMP and inositol phosphate production did not differ between sexes. The results demonstrate sex-related differences in atrial function that can be partially explained by greater myofibrillar Ca2+-sensitivity in females. A potential contribution of sarcolemmal Ca2+ influx is suggested by greater tetanic contraction in ryanodine-treated female atrium. The larger response of males to adrenergic stimulation does not appear to be explained by higher production of relevant second messengers. Future studies will investigate the role of sex hormones in these sexually dimorphic responses and may indicate a need for gender-specific therapeutic interventions for myocardial dysfunction.