Timir Paul

The effects of coronary artery calcium screening on behavioral modification, risk perception, and medication adherence among asymptomatic adults: A systematic review

OBJECTIVE To perform systematic review of the effects of screening for coronary artery calcium (CAC), a subclinical marker of coronary artery disease (CAD), on behavioral or lifestyle modification, risk perception, and medication adherence. METHODS We searched through CINAHL, PsychInfo, Web of Science, Cochrane Central Register of Control Trials, and PubMed (Medline) for studies on the effects of CAC screening in asymptomatic individuals across three major domains: behavioral modification, risk perception for CAD, and medication adherence. We extracted data from the retrieved studies, assessed and synthesized the information. RESULTS Of the 15 retrieved studies, three were randomized control trials and 12 were observational studies. CAC score was ascertained either as total score, quartiles, or standardized Agatstons ordinal scale. While all the 15 studies involved issues related to behavioral and medication adherence, four involved risk perception of CAD. Although no standardized approach was used in these studies, CAC screening enhanced medication adherence in 13 of the 15 studies, while the others were mixed. CONCLUSION CAC screening improved medication adherence and could likely motivated individuals for beneficial behavioral or lifestyle changes to improve CAD. The mixed results suggest the need for further research because screening for subclinical atherosclerosis has significant implications for early detection and prevention of future cardiovascular events by aggressive risk factors modification.

Subclinical atherosclerosis and relationship with risk factors of coronary artery disease in a rural population

Background:Annually, over 150,000 cardiovascular events occur among individuals <65 years old in the United States, including asymptomatic ones. Coronary artery calcium (CAC), a subclinical marker of coronary artery disease (CAD), enhances risk stratification among asymptomatic individuals. This study assessed the prevalence of CAC in a rural population and determined relationships between traditional risk factors for CAD and CAC scores. Methods:During January 2011 to December 2012, asymptomatic individuals from central Appalachia were screened for CAC in the largest tertiary cardiovascular institute. Based on Agatston scale, participants were grouped into 4 CAC scores: zero (CAC = 0), mild (CAC = 1–99), moderate (CAC = 100–399) and severe (CAC ≥ 400). Multinomial logistic regression was used to examine associations between potential risk factors of CAD and CAC score. Results:Of 1,674 participants, 55.4% had positive CAC score (CAC > 0). Increasing age and being male were positively associated with higher CAC scores. Although there was significant association between mild CAC and hypertension and family history of CAD, moderate CAC was positively associated with smoking status. Except hypercholesterolemia and sedentary lifestyle, severe CAC was significantly associated with major health conditions (obesity, diabetes and hypertension), lifestyle (smoking) and family history of CAD. Conclusions:More than half of participants in the CAC screening had subclinical CAD (CAC score > 0). The association between CAC score and CAD risk factors suggests that education about subclinical atherosclerosis among asymptomatic individuals in this region with high cardiovascular disease prevalence is needed because CAC improves CAD risk stratification, and the knowledge of CAC enhances medication adherence and motivates individuals towards beneficial behavioral/lifestyle modification.

The effects of multiple coronary artery disease risk factors on subclinical atherosclerosis in a rural population in the United States.

INTRODUCTION The risk factors for cardiovascular disease (CVD) are associated with coronary atherosclerosis and having multiple risk factors potentiates atherosclerosis. This study examined the prevalence of multiple biological and lifestyle/behavioral risk factors and their association with coronary artery calcium (CAC), a marker for subclinical coronary atherosclerosis. METHODS This is a cross-sectional study of 1607 community-dwelling asymptomatic individuals from central Appalachia who participated in CAC screening between January 2011 and December 2012. Data on demographics (sex and age) and 7 traditional risk factors for coronary artery disease (CAD) were collected and categorized into 5 groups (0-1, 2, 3, 4, and ≥5). Prevalence of these risk factors and CAC scores (0, 1-99, 100-399, ≥400) were assessed, and the impact of the number of risk factors on CAC scores were delineated using multiple logistic regression. RESULTS Over 98% of participants had ≥1 risk factor. While obesity, diabetes, hypertension, and family history of CAD significantly increased the odds of having CAC, CAC scores significantly increased with number of risk factors. After adjusting for demographic factors, having 3, 4, and ≥5 risk factors was significantly associated with increased odds of having higher CAC scores when compared to zero CAC score by more than one and half times [OR=1.65, CI (1.20-2.25)], two times [OR=2.32, CI (1.67-3.23)] and three times [OR=3.45, CI (2.42-4.92)], respectively. CONCLUSION The high prevalence of multiple risk factors in the study population suggests the need for aggressive multiple risk factors interventions for primary prevention of CAD, which could address CVD health disparities.

Obesity Cardiomyopathy: Pathophysiologic Factors and Nosologic Reevaluation☆

&NA; Cardiovascular disease in populations with obesity is a major concern because of its epidemic proportion. Obesity leads to the development of cardiomyopathy directly via inflammatory mediators and indirectly by obesity‐induced hypertension, diabetes and coronary artery diseases. The aim of this review article is to re‐visit the available knowledge and the evidence on pathophysiologic mechanisms of obesity‐related cardiomyopathy and to propose its placement into a specific category of myocardial disease.

Prevalence and changes of untreated isolated systolic hypertension among non-Hispanic black adults in the United States

Isolated systolic hypertension (ISH) is a growing health concern in the United States (US) black population. The stratified prevalence of untreated ISH has not been fully investigated in non-Hispanic blacks. Cross-sectional data on 4625 non-Hispanic blacks aged ⩾18 years were collected from the National Health and Nutrition Examination Survey 1999–2010, representing a probability sample of the US civilian noninstitutionalized black population. The 6-year prevalence of ISH and 95% confidence intervals (CIs) were estimated by conducting weighted frequency and logistic procedures. The prevalence of untreated ISH was 11.2% among non-Hispanic black adults in 1999–2010. Individuals who received lower education (high school or below) had higher prevalence of untreated ISH than those with higher education (12.8% (95% CI: 11.3–14.2%) vs. 9.0% (95% CI: 7.5–10.6%)). The prevalence of untreated ISH was higher in young men than in young women (4.3% (95% CI: 3.3–5.4%) vs. 1.8% (95% CI: 0.9–2.7%)), and higher in middle-aged adults with lower education than in middle-aged adults with higher education (14.1% (95% CI: 11.4–16.7%) vs. 7.7% (95% CI: 5.5–9.8%)). Compared with 1999–2004, the prevalence of untreated ISH in 2005–2010 decreased for old individuals (27.7% vs. 40.8%), old men (24.4% vs. 40.0%) and old individuals who received higher education (21.4% vs. 40.7%). Untreated ISH is more prevalent in old blacks, and significant reduction of the prevalence in this group suggests that public health interventions, lifestyle modifications or health awareness are in the right direction.

Arrhythmogenic Right Ventricular Cardiomyopathy: A Case Presentation with a Review

Arrhythmogenic Right Ventricular Cardiomyopathy: A Case Presentation with a Review Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare but well known cause of sudden cardiac death (SCD) and malignant arrhythmias. Here we present a case of ARVC in a 26 year old male who had presented with syncope, palpitations and fatigue. Electrocardiogram (ECG) showed epsilon waves and T-wave inversion (TWI) in V1-V3, prolonged QTc of 498 msec and slurred S wave (>55 msec). He was discharged from the hospital on a betablocker and further evaluation with cardiac magnetic resonance imaging (MRI) as well as genetic testing was planned. This case indicates that any younger and middle-age patient who presents with syncope or palpitations, ARVC should be a differential and further work up with any non-invasive modality should be performed provided that there is a high suspicion of ARVC as in this patient with ECG findings suggestive of ARVC.

Cardiovascular Critical Care: A Perceived Deficiency among U.S. Trainees

Objective:Acute and chronic cardiovascular comorbidities are common among critically ill individuals. It is unclear if current critical care fellowship trainees feel adequately prepared to manage these conditions. Design:Prospective, cross-sectional survey. Patients or Subjects:Trainees enrolled in U.S. critical care training programs. Setting:Accredited pulmonary/critical care, surgery/critical care, anesthesiology/critical care, and stand-alone critical care training programs. Interventions:None. Measurements and Main Results:A 19-item survey assessing trainee confidence in the management of cardiac critical illness and the performance of cardiac-specific critical care interventions was constructed using Accreditation Council for Graduate Medical Education recommendations as a reference. After validation, the survey was electronically sent to all training programs for dissemination to their trainees. Confidence scores were measured on a Likert scale from 1 to 5. A total of 134 completed surveys were analyzed. Overall, respondents reported lower confidence in managing cardiovascular compared with noncardiovascular diseases in the ICU (4.0 vs 4.6 out of 5). Likewise, they reported lower perceived competence in performing cardiovascular procedures specific to the ICU (2.9 vs 4.5 out of 5). The majority (88%) of those surveyed felt that they would benefit from increased didactic and clinical experience in the management of cardiovascular critical illness. Conclusions:Current critical care fellows may be unprepared to deal with the increasing prevalence of cardiovascular illness in the ICU. This potential educational gap warrants timely attention to ensure that future graduates have the requisite skills necessary to manage these critically ill patients and presents a unique opportunity to develop multidisciplinary partnerships for enhancing training.

Association between Multiple Modifiable Risk Factors of Cardiovascular Disease and Hypertension among Asymptomatic Patients in Central Appalachia

Objectives The central Appalachian region of the United States is disproportionately burdened with cardiovascular diseases (CVD) and associated risk factors; however, research to inform clinical practice and policies and programs is sparse. This study aimed to examine the association between multiple modifiable risk factors for CVD and hypertension in asymptomatic patients in central Appalachia. Methods Between January 2011 and December 2012, 1629 asymptomatic individuals from central Appalachia participated in screening for subclinical atherosclerosis. Participants were asked to report their hypertension status (yes/no). In addition, data on two nonmodifiable risk factors (sex, age) and five modifiable risk factors (obesity, diabetes mellitus, hypercholesterolemia, smoking, and sedentary lifestyle) were collected. Multivariable logistic regression analyses were conducted to assess association between hypertension and risk factors. Results Of the 1629 participants, approximately half (49.8%) had hypertension. Among people with hypertension, 31.4% were obese and 62.3% had hypercholesterolemia. After adjusting for sex and age, obesity and diabetes mellitus were associated with a more than twofold increased odds of having hypertension (odds ratio [OR] 2.02, confidence interval [CI] 1.57–2.60 and OR 2.30, CI 1.66–3.18, respectively). Hypercholesterolemia and sedentary lifestyle were associated with higher odds for hypertension (OR 1.26, CI 1.02–1.56 and OR 1.38, CI 1.12–1.70, respectively), compared with referent groups. Having two, three, and four to five modifiable risk factors was associated with increased odds of having hypertension by about twofold (OR 1.72, CI 1.21–2.44), 2.5-fold (OR 2.55, CI 1.74–3.74), and sixfold (OR 5.96, CI 3.42–10.41), respectively. Conclusions This study suggests that the odds of having hypertension increases with a higher number of modifiable risk factors for CVD. As such, implementing an integrated CVD program for treating and controlling modifiable risk factors for hypertension would likely decrease the future risk of CVD.

Outcomes of Saphenous Vein Graft Intervention With and Without Embolic Protection Device: A Comprehensive Review and Meta-Analysis

Background— Current guidelines give a class I recommendation to use of embolic protection devices (EPD) for saphenous vein graft (SVG) intervention; however, studies have shown conflicting results. The objective of this meta-analysis is to compare all-cause mortality, major adverse cardiovascular events, myocardial infarction (MI), or target vessel revascularization in SVG intervention with and without EPD. Methods and Results— Literature was searched through October 2016. Eight studies (n=52 893) comparing SVG intervention performed with EPD (n=11 506) and without EPD (n=41 387) were included. There was no significant difference in all-cause mortality (odds ratio [OR], 0.79; confidence interval [CI], 0.55–1.12; P=0.19), major adverse cardiovascular events (OR, 0.73, CI, 0.51–1.05; P=0.09), target vessel revascularization (OR, 1.0; CI, 0.95–1.05; P=0.94), periprocedural MI (OR, 1.12; CI, 0.65–1.90, P=0.69), and late MI (OR, 0.80; CI, 0.52–1.23; P=0.30) between the 2 groups. Sensitivity analysis excluding CathPCI Registry study showed no difference in periprocedural MI, late MI, and target vessel revascularization; however, it favored EPD use in all-cause mortality and major adverse cardiovascular events. Further sensitivity analysis including only observational studies revealed no difference in all-cause mortality, major adverse cardiovascular events, target vessel revascularization, and late MI. Additional analysis after excluding CathPCI Registry study revealed no difference in outcomes. Conclusions— This study including 52 893 patients suggests no apparent benefit in routine use of EPD during SVG intervention in the contemporary real-world practice. Further randomized clinical trials are needed in current era to evaluate long-term outcomes in routine use of EPD, and meanwhile, current guideline recommendations on EPD use should be revisited.

Mortality and major adverse cardiovascular events after transcatheter aortic valve replacement using Edwards valve versus CoreValve: A meta-analysis ☆,☆☆

OBJECTIVES In patients with severe aortic stenosis who are at high risk for surgery, transcatheter aortic valve replacement (TAVR) has emerged as an alternative procedure using EV or CV. The objective of this meta-analysis is to compare 1-year mortality and major adverse cardiovascular and cerebrovascular events (MACCE) between Edwards valve (EV) and Medtronic CoreValve (CV). METHODS PubMed and the Cochrane Center Register of Controlled Trials were searched through December 2014. Twenty seven studies (n=12,249) comparing TAVR procedure that used EV (n=5745) and CV (n=6504) were included. End points were procedural success rates, post-procedural mortality, myocardial infarction (MI), stroke, major bleeding, major vascular complications, incidence of new permanent pacemaker (PPM) placement and new left bundle branch block (LBBB). The odds ratio (OR) with 95% confidence interval (CI) was computed and p<0.05 was considered for significance. RESULTS There were no significant differences between EV and CV for post-procedural in-hospital, 30-day and 1-year all-cause mortality rates (p=0.53, 0.33 and 0.94 respectively), cardiovascular mortality (p=0.61), stroke (p=0.54), major bleeding (p=0.25) and major vascular complications (p=0.27). MI was significantly lower with EV compared to CV (OR: 0.56, CI: 0.35-0.89, p=0.01). Placement of new PPM and new onset LBBB were significantly higher in CV compared to EV (OR: 3.35, CI: 2.96-3.79, p<0.00001 and OR: 6.55, CI: 4.76-9.03, p<0.00001 respectively). CONCLUSIONS The results of our meta-analysis suggest that TAVR procedure using CV may be associated with a higher incidence of MI, new PPM placement, and new onset LBBB compared to EV. However, the type of valve placed does not affect mortality.