Robert J. Ostfeld

Obstructive sleep apnea and acute myocardial infarction severity: Ischemic preconditioning?

BackgroundObstructive sleep apnea (OSA) is characterized by intermittent hypoxia (IH). In animal models, IH has been shown to protect the myocardium during periods of ischemia by reducing infarct size. However, this phenomenon of “ischemic preconditioning” has not been investigated among OSA patients with acute myocardial infarction (MI). This study investigates the role of OSA on MI severity as measured by cardiac enzymes, specifically troponin-T, among patients with an acute MI.MethodsThis is an observational cohort study of patients ≥18xa0years of age who were hospitalized with an acute MI. Each participant underwent portable sleep monitoring (Apnea Link Plus); OSA was defined as an apnea–hypopnea index ≥5/h. Multivariable regression analysis was conducted to assess the relationship between OSA and highly sensitive troponin-T levels.ResultsIn our entire cohort of acute MI patients (nu2009=u2009136), 77xa0% of the sample had evidence of sleep disordered breathing, with 35xa0% of the sample having OSA (i.e., an AHI >5). Higher AHI was associated with lower peak troponin-T levels in partially adjusted models (βu2009=u2009−0.0320, pu2009=u20090.0074, adjusted for age, gender, and race) and fully adjusted models (βu2009=u2009−0.0322, pu2009=u20090.0085) (additionally adjusted for smoking, hypertension, hyperlipidemia, body mass index, history of prior cardiovascular or cerebrovascular disease, diabetes and baseline admission creatinine levels). The mean value of the log-transformed peak troponin-T variable was used to dichotomize the outcome variable. In both partially (OR 0.949, CI 0.905–0.995, pu2009=u20090.03) and fully adjusted (OR 0.918, CI 0.856–0.984, pu2009=u20090.0151) logistic regression models, the OR for AHI suggests a protective effect on high troponin-T level.ConclusionsOur study demonstrates that patients with OSA have less severe cardiac injury during an acute non-fatal MI when compared to patients without OSA. This may suggest a cardioprotective role of sleep apnea during acute MI via ischemic preconditioning.

The significance of transient ischemic dilation in the setting of otherwise normal SPECT radionuclide myocardial perfusion images

BackgroundTransient ischemic dilation (TID) in the setting of an abnormal SPECT radionuclide myocardial perfusion imaging (MPI) study is considered a marker of severe and extensive coronary artery disease (CAD). However, the clinical significance of TID and its association with CAD in patients with an otherwise normal MPI study is unclear.MethodsFrom a database of patients who underwent MPI over a 9-year period, 96 without known cardiac history who had normal image perfusion patterns, and who underwent coronary angiography within 6xa0months, were identified. TID quantitative values were derived. To adjust for varying stress and image protocols, a TID index based on published threshold values was derived for each patient, with >1 considered as TID. We examined the relationship of TID to the presence/extent of CAD, and to a CAD prognostic index. TID was also correlated with patient survival. To address referral bias, survival in a separate cohort of 3,691 patients with a normal perfusion MPI who did not undergo angiography in the 6-month interval was correlated with the presence and severity of TID.ResultsFor 28 (29.2%) patients with normal MPI perfusion patterns but with TID, there was no increased incidence of CAD, multivessel or left main disease, or a higher prognostic index compared with no TID. In addition, there was no increased mortality associated with TID in both the angiography cohort and in the patients who did not undergo immediate angiography.ConclusionsTID in patients with an otherwise normal SPECT MPI study does not increase the likelihood of CAD, its extent or severity, and is not associated with worsened patient survival.

The effect of beta-blockers on the diagnostic accuracy of vasodilator pharmacologic SPECT myocardial perfusion imaging.

BackgroundThe effect of beta (β) blockers on the accuracy, particularly the sensitivity, of vasodilator radionuclide myocardial perfusion imaging (MPI) is not entirely clear. This study aimed to further assess the effect of β-blockers on the ability of MPI to identify significant and high-risk coronary artery disease (CAD).Methods and ResultsFor 555 patients who underwent vasodilator MPI and had coronary angiography within 90xa0days, global and per-vessel sensitivities and specificities were calculated, and were found to be similar between patients taking β-blockers and those who were not. β-blockers did not decrease the ability to detect patients with multivessel disease. Summed stress scores and summed rest scores were likewise similar in both groups. To account in part for catheterization referral bias and the potential of false-negative MPI studies in patients receiving β-blockers, survival analysis was performed on 2646 patients with normal MPI studies who did not undergo cardiac catheterization and failed to demonstrate significant mortality difference related to the taking of β-blockers.Conclusionsβ-blocker therapy does not diminish the ability of vasodilator stress MPI to detect clinically significant CAD, nor hide the mortality risk of patients with normal studies not referred for catheterization.

Knowledge and Orientations of Internal Medicine Trainees Toward Periodontal Disease

BACKGROUNDnThere is growing evidence that periodontal disease may be a source of systemic inflammation that impacts overall health. As such, periodontal disease is associated with an increased risk of systemic illnesses such as cardiovascular disease and adverse outcomes in diabetes mellitus and pregnancy. With the aim of assessing oral health knowledge and orientations of physicians in training, we surveyed incoming internal medicine trainees about their general knowledge, attitudes, and behaviors/practices about periodontal health and disease.nnnMETHODSnA 16-question survey was distributed during orientation to incoming internal medicine trainees at a single urban teaching hospital in New York City in 2007 and 2008. Questions aimed to assess the knowledge levels of the subjects about periodontal disease and their attitudes toward discussing/evaluating the periodontal status of their patients. The study was approved by the Montefiore Institutional Review Board.nnnRESULTSnOf 125 incoming medical trainees queried, 115 responded (92% response rate). Of the 115 responders, 96% were medical interns. The median age of the trainees was 27 years (interquartile range: 26 to 29 years), and 61% were female. Overall, 34% of the trainees answered all five true/false general knowledge questions correctly, 82% reported that they never asked patients if they were diagnosed with periodontal disease, 90% reported not receiving any training about periodontal disease during medical school, 69% reported that they were not comfortable at all performing a simple periodontal examination, 17% agreed that patients expect physicians to discuss/screen for periodontal disease, 46% felt that discussing/evaluating the periodontal status of their patients was peripheral to their role as physicians, 76% reported never screening patients for periodontal disease, and 23% stated that they never referred patients to dentists.nnnCONCLUSIONSnIn this study, incoming internal medicine trainees had inadequate knowledge regarding periodontal disease. They were also generally uncomfortable with performing a simple periodontal examination. Oral health training in medical school and the medical postgraduate setting is recommended.

Internal Medicine Interns Have a Poor Knowledge of Peripheral Artery Disease

Peripheral arterial disease (PAD) is common and carries an increased risk of morbidity and mortality. The level of knowledge among incoming medical trainees about PAD is unknown. During orientation to a single internal medicine residency program, incoming medical interns were given a 19-question multiple-choice questionnaire. The questions fell into 1 of 4 categories about PAD: (1) prevalence, (2) screening, (3) treatment, and (4) outcome. Sixty-two incoming interns were queried. The percentage of questions answered correctly overall was 41.7% (10.5%-73.7%). The percentage of questions answered correctly in the prevalence, screening, treatment, and outcome groups were 48.9% (0 to 100%), 33.8% (0 to 80%), 45.0% (0 to 87.5%), and 42.5% (0 to 100%), respectively. Internal medicine interns have poor knowledge about PAD including its prevalence, screening, treatment, and outcomes. Increased education during medical school is encouraged.

The Deficit of Nutrition Education of Physicians

Globally, death rates from cardiovascular disease are increasing, rising 41% between 1990 and 2013, and are often attributed, at least in part, to poor diet quality. With urbanization, economic development, and mass marketing, global dietary patterns have become more Westernized to include more sugar-sweetened beverages, highly processed foods, animal-based foods, and fewer fruits and vegetables, which has contributed to increasing cardiovascular disease globally. In this paper, we will examine the trends occurring globally in the realm of nutrition and cardiovascular disease prevention and also present new data that international nutrition knowledge amongst cardiovascular disease providers is limited. In turn, this lack of knowledge has resulted in less patient education and counseling, which is having profound effects on cardiovascular disease prevention efforts worldwide.

A Clinician's Guide for Trending Cardiovascular Nutrition Controversies: Part II

The potential cardiovascular (CV) benefits of many trending foods and dietary patterns are still incompletely understood, and scientific inquiry continues to evolve. In the meantime, however, a number of controversial dietary patterns, foods, and nutrients have received significant media attention and are mired by hype. This second review addresses some of the more recent popular foods and dietary patterns that are recommended for CV health to provide clinicians with current information for patient discussions in the clinical setting. Specifically, this paper delves into dairy products, added sugars, legumes, coffee, tea, alcoholic beverages, energy drinks, mushrooms, fermented foods, seaweed, plant and marine-derived omega-3-fatty acids, and vitamin B12.

Prevention information: Patient perceptions regarding general and race-based instruction

INTRODUCTIONnThe benefits of a healthy lifestyle are well-known. However, translating such information into behavior change is challenging. We explored patient perception in regard to how frequently this information is being disseminated, whether it may alter patient behavior, and whether information tailored to race versus general information is desirable.nnnMETHODSnConsecutive patients were asked to fill out an anonymous questionnaire directly prior to an outpatient cardiologist visit from 2006-2007. Six Likert scale questions were asked regarding physician education, its impact on behavior change, and the potential of race-based information to cause additional behavior change.nnnRESULTSnTwo hundred and six patients were queried, and 150 subjects completed the questionnaire. Mean age was 59 (+/-16) years, and 36% of the patients were men. Overall, 85% of patients reported being educated about lifestyle change. A large majority (greater than two-thirds) of the responders agreed or strongly agreed that education helps them make lifestyle changes, and that race-based information would be superior to general, non-race-based information in motivating lifestyle change. The responses were significantly higher than a hypothetical neutral score (p<.001) using the Wilcoxon rank-sum test.nnnCONCLUSIONSnAs a team, physicians are doing a good job disseminating preventive information. Patients report that this information does or will translate into behavior change. Information tailored to race appears to provide a superior impetus for the adoption of behavior change. Ongoing tailored education regarding a healthy lifestyle is warranted. Whether this information will lead to actual behavior change or to changes in clinical events requires further study.

A plant-based diet and hypertension

Hypertension is an insidious, common, and deadly disease, often detected incidentally at a routine doctor’s visit or workplace health screening. Worldwide, it is estimated that one billion people have hypertension and approximately 80 million Americans 20 years of age and older are hypertensive. The National Health and Nutrition Data Examination Survey found that only 54% of hypertensive adults in the United States had their high blood pressure controlled and 17% remained undiagnosed. These findings translate into poor outcomes as the number of deaths due to hypertension increased by 35% from 2003–2013. In the Global Burden of Disease 2010 study, hypertension was identified as the number one risk factor worldwide for deaths and disability-adjusted life years. In the United States, clinic visits, medications and the treatment of complications from hypertension, including heart failure, stroke, and renal disease now account for a substantial portion of the Medicare budget. uf020 First line therapies for all stages of hypertension include exercise and weight loss. However, results from one small cross-sectional study suggest that a plant-based diet is the more important intervention. This study compared the blood pressure of sedentary vegans, endurance athletes (matched for body mass index with the vegan group) consuming a Western diet and running an average of 48 miles per week, and sedentary subjects consuming a Western diet. Blood pressure was significantly lower in the vegan group. Although the benefits of exercise and weight loss seem to be inherently understood by most, the definition and perception of a “healthy” diet is one that has not yet reached consensus. In the late 1930 s, Dr. Walter Kempner of Duke University introduced the “rice diet” as therapy for renal failure and hypothesized that “we could radically alter the patients’ diets and thereby save lives.” The rice diet was high in

Attitudes of inner city patients with cardiovascular disease towards meditation.

Objectives Meditation is a stress reduction intervention that is of potential benefit to patients with cardiovascular disease, but its interest in inner city cardiology patients is unknown. We surveyed patients at an inner city cardiology clinic about their interest in learning meditation and the impact of stress on their lifestyles. Methods A survey was distributed to 215 consecutive patients in an inner city cardiology clinic. Chi-square tests were used to compare those interested and not interested in meditation. Results Of the 215 surveys, 54 were excluded because of 2 or more missing responses, leaving 161 for analysis. The mean age was 61 (+/− 16.5) years; 59% were female, 37% were black non-Hispanic, and 34% were Hispanic, and 18% were white. Overall, 46% expressed interest in learning meditation, and 64% agreed that less stress would facilitate living a healthy lifestyle. In subgroup analysis, the highest levels of interest in meditation classes occurred in patients who were younger than 65 years old (69% interested) and those who agreed that less stress would facilitate living a healthy lifestyle (71% interested). Conclusion Many of the patients at an inner city cardiology clinic may have interest in learning meditation. Given the effects of stress in this population, clinical trials involving meditation are warranted.