Suzanne Adams

Prevalence of Hypovitaminosis D in Cardiovascular Diseases (from the National Health and Nutrition Examination Survey 2001 to 2004)

This cross-sectional study examined the burden of cardiovascular diseases (CVDs) using serum 25-hydroxyvitamin D (25[OH]D) and prevalence of hypovitaminosis D in adults with CVDs using data from NHANES 2001 to 2004. Serum 25(OH)D levels were divided into 3 categories (> or =30, 20 to 29, and <20 ng/ml), and hypovitaminosis D was defined as vitamin D <30 ng/ml. Of 8,351 adults who had 25(OH)D measured, mean 25(OH)D was 24.3 ng/ml, and the prevalence of hypovitaminosis D was 74%. The burden of CVDs increased with lower 25(OH)D categories, with 5.3%, 6.7%, and 7.3% coronary heart disease; 1.5%, 2.4%, and 3.2% heart failure; 2.5%, 2.0%, and 3.2% stroke; and 3.6%, 5.0%, and 7.7% peripheral arterial disease. Across all CVDs, hypovitaminosis D was more common in blacks than Hispanics or whites. Compared with persons at low risk for CVDs (68%), it was more prevalent in those at high risk (75%; odds ratio [OR] 1.32, 95% confidence interval [CI] 1.05 to 1.67), with coronary heart disease (77%; OR 1.48, 95% CI 1.14 to 1.91), and both coronary heart disease and heart failure (89%; OR 3.52, 95% CI 1.58 to 7.84) after controlling for age, race, and gender. In conclusion, hypovitaminosis D was highly prevalent in US adults with CVDs, particularly those with both coronary heart disease and heart failure.

The changing face of postoperative atrial fibrillation prevention: a review of current medical therapy.

Atrial fibrillation is the most common postoperative arrhythmia with significant consequences on patient health. Postoperative atrial fibrillation (POAF) complicates up to 8% of all noncardiac surgeries, between 3% and 30% of noncardiac thoracic surgeries, and between 16% and 46% of cardiac surgeries. POAF has been associated with increased morbidity, mortality, and longer, more costly hospital stays. The risk of POAF after cardiac and noncardiac surgery may be affected by several epidemiologic and intraoperative factors, as well as by the presence of preexisting cardiovascular and pulmonary disorders. POAF is typically a transient, reversible phenomenon that may develop in patients who possess an electrophysiologic substrate for the arrhythmia that is present before or as a result of surgery. Numerous studies support the efficacy of &bgr;-blockers in POAF prevention; they are currently the most common medication used in POAF prophylaxis. Perioperative amiodarone, sotalol, nondihydropyridine calcium channel blockers, and magnesium sulfate have been associated with a reduction in the occurrence of POAF. Biatrial pacing is a nonpharmacologic method that has been associated with a reduced risk of POAF. Additionally, recent studies have demonstrated that hydroxymethylglutaryl-CoA reductase inhibitors may decrease the risk of POAF. Finally, based on recent evidence that angiotensin converting enzyme inhibitors and angiotensin receptor blockers reduce the risk of permanent atrial fibrillation, these medications may also hold promise in POAF prophylaxis. However, there is a need for further large-scale investigations that incorporate standard methodologies and diagnostic criteria, which have been lacking in past trials.

Aspirin and clopidogrel use in the early postoperative period following on-pump and off-pump coronary artery bypass grafting

OBJECTIVE Preoperative use of clopidogrel increases the risk of bleeding, but its postoperative use has not been studied. We studied early postoperative clopidogrel use in on-pump and off-pump coronary artery bypass grafting. METHODS Data were obtained from the University HealthSystem Consortium database. We conducted a retrospective analysis of data of 15,067 adults who had coronary artery bypass grafting between 2003 and 2006 and received perioperative aspirin alone or in combination with clopidogrel, with the latter administered within 2 days after coronary artery bypass grafting. Logistic regression was used to analyze in-hospital mortality, 30-day readmission, ischemic or thrombotic events, and bleeding events, with propensity score adjustment for clopidogrel treatment. RESULTS Combined aspirin and clopidogrel were used in 3268 patients (22%). Compared with aspirin alone, aspirin plus clopidogrel was associated with reductions of in-hospital mortality (0.95% vs 1.78%; adjusted odds ratio: 0.50; 95% confidence interval: 0.25, 0.99) and bleeding events (4.19% vs 5.17%; adjusted odds ratio: 0.70; 95% confidence interval: 0.51, 0.97). Ischemic or thrombotic events were not significantly different (1.29% vs 1.53%; adjusted odds ratio, 0.99; 95% confidence interval: 0.59, 1.64). The relative effect of combined treatment did not differ between on-pump and off-pump coronary artery bypass grafting. CONCLUSIONS Early postoperative clopidogrel combined with aspirin may be safe and beneficial compared with perioperative aspirin treatment alone, in both on-pump and off-pump coronary artery bypass grafting. However, a possibility of selection bias calls for randomized controlled trials to confirm our findings.

Saphenous vein graft disease: review of pathophysiology, prevention, and treatment.

Saphenous vein graft (SVG) disease after coronary artery bypass grafting (CABG) occurs in three phases: thrombosis, intimal hyperplasia, and atherosclerosis. Within the first month, thrombosis plays a major role. From month 1 to month 12, intimal hyperplasia occurs. Beyond 12 months, atherosclerosis becomes the primary cause for late graft failure. Endothelial damage has been shown to be the major underlying pathophysiology of SVG disease. Many factors contribute to endothelial damage from the moment the vein is harvested to when the vein is grafted into an arterial environment. To address this disease process, various therapeutic modalities, from surgical methods to medical treatment, have been evaluated. Surgically, the technical method of harvesting the vein has been shown to affect SVG patency. From a pharmacologic perspective, only two guideline class I recommended medications, aspirin and statins, have been shown to improve short- and long-term SVG patency after CABG. Despite these surgical and medical advances, SVG disease remains a significant problem with 1-year patency rates of 89% dropping to 61% after 10 years. This review discusses the pathogenesis of SVG disease, predictors of SVG failure, and current surgical and pharmacologic therapies to address SVG disease, including possible future treatment.

Modifiable cardiovascular risk factors among individuals in low socioeconomic communities and homeless shelters.

To understand cardiovascular health in low socioeconomic populations, we analyzed the data from 426 low socioeconomic community-dwelling males and females and 287 homeless males in Philadelphia. Despite higher prevalence of smoking and hypertension, the proportion of homeless participants at increased risk for coronary heart disease was comparable with that of low socioeconomic community-dwelling participants. Among various characteristics, emotional stress was significantly associated with coronary heart disease risk in low socioeconomic community-dwelling participants only, suggestive of a differential psychosocial effect of stress. Our findings suggest that low socioeconomic populations are heterogeneous with respect to their risk factors and needs for interventions.

Heart Failure Patient Adherence: Epidemiology, Cause, and Treatment

Poor adherence to therapeutic regimens is a significant impediment to improving clinical outcomes in the HF population. Typical rates of adherence to prescribed medications, low-sodium diets, and aerobic exercise programs remain lower than that needed to decrease morbidity and mortality associated with HF. Factors contributing to poor adherence include multiple comorbidities, clinical depression, and decreased cognitive functioning. HF education and programs to enhance self-management skills have improved patient quality of life but have yet to decrease mortality or rehospitalization rates significantly. Telemonitoring to improve adherence behaviors and self-management interventions within broader HF management programs have demonstrated significant clinical improvements in this population.

Renal dysfunction in heart failure patients: what is the evidence?

Congestive heart failure (CHF) is an increasingly common medical condition and the fastest growing cardiovascular diagnosis in North America. Over one-third of patients with heart failure also have renal insufficiency. It has been shown that renal insufficiency confers worsened outcomes to patients with heart failure. However, a majority of the larger and therapy-defining heart failure medication and device trials exclude patients with advanced renal dysfunction. These studies also infrequently perform subgroup analyses based on the degree of renal dysfunction. The lack of information on heart failure patients who have renal insufficiency likely contributes to their being prescribed mortality and morbidity reducing medications and receiving diagnostic and therapeutic procedures at lower rates than heart failure patients with normal renal function. Inclusion of patients with renal insufficiency in heart failure studies and published guidelines for medication, device, and interventional therapies would likely improve patient outcomes.

Racial disparity in the relationship between hospital volume and mortality among patients undergoing coronary artery bypass grafting.

Objective:To examine whether the volume-mortality relationship in coronary artery bypass grafting (CABG) differs by race and operative risk. Summary Background Data:In-hospital mortality after CABG is inversely associated with hospital volume. Racial disparities exist in the outcomes of CABG, possibly due to blacks’ high operative risk. Methods:We analyzed 71,949 CABG procedures performed between 2002 and 2005 at 93 academic medical centers participating in the University HealthSystem Consortium. In-hospital mortality was examined across hospital volume categories (very low, <100/yr; low, 100–299/yr; medium, 300–499/yr; and high, ≥500/yr) via logistic regression. Results:In-hospital mortality was 2.0% in whites and 2.8% in blacks. Controlling for patient risk, geographic region, and proportion of African American patients treated at the hospital, the benefit of higher volume was substantial for blacks but only modest for whites (race-by-volume interaction; P = 0.033). Odds ratios of mortality for increasing volume categories (compared with very low volume) were 0.46, 0.37, and 0.47 among blacks but only 0.85, 0.77, and 0.75 among whites. Racial disparities in mortality existed mostly in very low-volume hospitals. The differential volume effect across the 2 racial groups seemed to be primarily driven by regional patterns, as the volume effect was much more pronounced in the South and the Midwest (region by volume interaction; P = 0.033). Conclusions:Blacks have greater reduction in mortality than whites by undergoing CABG at higher-volume hospitals, regardless of operative risk. Because of limited generalizability, these findings should be confirmed using more representative database.

Safety of Iodinated Intravenous Contrast Medium Administration in Sickle Cell Disease

BACKGROUND Increased sickling of erythrocytes following intravenous iodinated contrast has been described in patients with sickle cell disease. In vitro, the effect is correlated with the tonicity, viscosity, acidity, and ionic nature of contrast media. Less erythrocyte sickling is observed in vitro with second-generation low- and iso-osmolar contrast agents. Clinical impact of these newer intravenous contrast agents has not been investigated. PURPOSE To review adverse outcomes following contrast administration in a cohort of patients with sickle cell disease. METHODS Inpatients with sickle cell disease who received iodinated intravenous were identified. Medical records were reviewed for evidence of worsening crisis and occurrence of adverse events within 48 hours of contrast administration. Data points were further analyzed with the goal of identifying predictors of adverse outcome. RESULTS There were 132 imaging studies that met inclusion criteria in 79 patients, mostly with homozygous hemoglobin S. The low-osmolar contrast Optiray (Coviden Imaging Inc., Hazelwood, Mo) was used in 45%. Administration of fluids, Mucomyst (Bristol-Myers Squibb, New York, NY), oxygen, or blood transfusion preceded 58% of studies. Minor adverse events followed 16% of studies, with new or worsening pain being most common (12%). Contrast-induced nephropathy occurred in 1.5%, resolving in all cases. Prehydration was associated with a decreased incidence of adverse events (P=.02). CONCLUSION Adverse events related to intravenous contrast occur in sickle cell disease patients at a rate similar to the general population, without an increase in contrast-induced nephropathy. Subjective reports of new or worsening pain crisis do not translate to objective findings. Beneficial diagnostic imaging can be performed without increased risk of serious complication in this population.

The physician-hospital team: a successful approach to improving care in a large academic medical center.

Initiatives to improve the quality and efficiency of care in academic medical centers (AMCs, teaching hospitals) can benefit the performance of academic departments as well as the hospital. However, the value of performance improvement programs in an AMC is often challenging. At Jefferson Medical College, clinical efficiency and bed availability are important priorities to the Department of Medicine. To this end, a multidisciplinary program was designed to (1) improve the quality and consistency of care by adapting and adopting national guidelines for patients with heart failure and acute coronary syndrome; (2) identify and improve hospital operational supports and maximize resource utilization; (3) increase hospital functional capacity to make way for increased volume; and (4) improve housestaff education and practice by using evidence-based approaches and by optimizing teaching relationships between housestaff and attending faculty. The eight-month project (November 2002 to July 2003) resulted in improvement in several quality measures including increased use of beta blockers and angiotensin converting enzyme inhibitors for heart failure patients, reduced length of stay for heart failure and acute coronary syndrome patients, and increased satisfaction of the clinicians involved in caring for these patients. However, the project was not without barriers including individual physician’s unwillingness to embrace change and an inability to incentivize change. Development of faculty leadership skills and enhanced physician accountability helped in overcoming the challenges of change.