Tina Shah

Why do some recovered peripartum cardiomyopathy mothers experience heart failure with a subsequent pregnancy

Opinion statementAfter concerns about survival and recovery from peripartum cardiomyopathy (PPCM), the question commonly asked is, “Is it safe to have another pregnancy?” While important advances have been made in the past decade in the recognition and treatment of PPCM, we still do not know why some apparently recovered PPCM mothers have a relapse of heart failure in a subsequent pregnancy. Knowing that some risk for relapse is always present, careful monitoring of the post-PPCM pregnancy is currently the best way to enable earlier diagnosis with institution of effective evidence-based treatment. In that situation it is reassuring to observe that when a subsequent pregnancy begins with recovered left ventricular systolic function to echocardiographic ejection fraction ≥0.50, even with relapse, the response to treatment is good with much more favorable outcomes. On the other hand, beginning the subsequent pregnancy with echocardiographic ejection fraction <0.50 greatly increases the risk for less favorable outcomes. This article summarizes the current state of knowledge; addresses the important questions facing patients, their families, and caregivers; and identifies the need for a prospective multi-center study of women with post-PPCM pregnancies. The reality is that an estimated 10 % to 20 % of apparently recovered PPCM mothers are going to relapse in a post-PPCM pregnancy; but we do not yet know why. Nevertheless, the lowest risk for relapse is experienced by those who (1) recover to left ventricular ejection fraction 0.55 prior to another pregnancy; (2) have no deterioration of left ventricular ejection fraction after phasing out angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker treatment following recovery; and perhaps, (3) demonstrate adequate contractile reserve on exercise echocardiography.

An Update on Gender Disparities in Coronary Heart Disease Care.

Coronary heart disease (CHD), traditionally considered a male disease, causes far more deaths in women than cancer. The prevalence of CHD is lower in women at any age, but with advancing age, this differential decreases. The clinical outcomes including myocardial infarction mortality, all-cause mortality, and reinfarction rates are also worse in women with cardiovascular diseases (CVD) than in men. Yet, women appear to be underdiagnosed and undertreated for coronary heart disease. There is still a gap in the knowledge, understanding, and general awareness of CHD in women. This review provides updates in gender disparities in the management of risk factors, treatments, and outcomes of coronary heart disease.

Meditation and Cardiovascular Risk Reduction: A Scientific Statement From the American Heart Association

Abstract Despite numerous advances in the prevention and treatment of atherosclerosis, cardiovascular disease remains a leading cause of morbidity and mortality. Novel and inexpensive interventions that can contribute to the primary and secondary prevention of cardiovascular disease are of interest. Numerous studies have reported on the benefits of meditation. Meditation instruction and practice is widely accessible and inexpensive and may thus be a potential attractive cost‐effective adjunct to more traditional medical therapies. Accordingly, this American Heart Association scientific statement systematically reviewed the data on the potential benefits of meditation on cardiovascular risk. Neurophysiological and neuroanatomical studies demonstrate that meditation can have long‐standing effects on the brain, which provide some biological plausibility for beneficial consequences on the physiological basal state and on cardiovascular risk. Studies of the effects of meditation on cardiovascular risk have included those investigating physiological response to stress, smoking cessation, blood pressure reduction, insulin resistance and metabolic syndrome, endothelial function, inducible myocardial ischemia, and primary and secondary prevention of cardiovascular disease. Overall, studies of meditation suggest a possible benefit on cardiovascular risk, although the overall quality and, in some cases, quantity of study data are modest. Given the low costs and low risks of this intervention, meditation may be considered as an adjunct to guideline‐directed cardiovascular risk reduction by those interested in this lifestyle modification, with the understanding that the benefits of such intervention remain to be better established. Further research on meditation and cardiovascular risk is warranted. Such studies, to the degree possible, should utilize randomized study design, be adequately powered to meet the primary study outcome, strive to achieve low drop‐out rates, include long‐term follow‐up, and be performed by those without inherent bias in outcome.

Statin Use and Its Facility-Level Variation in Patients With Diabetes: Insight From the Veterans Affairs National Database

We sought to determine use of any and at least moderate‐intensity statin therapy in a national sample of patients with diabetes mellitus (DM), with the hypothesis that nationwide frequency and facility‐level variation in statin therapy are suboptimal. We sampled patients with DM age 40 to 75 years receiving primary care between October 1, 2012, and September 30, 2013, at 130 parent facilities and associated community‐based outpatient clinics in the Veterans Affairs Health Care System. We examined frequency and facility‐level variation in use of any or at least moderate‐intensity statin therapy (mean daily dose associated with ≥30% low‐density lipoprotein cholesterol lowering). In 911 444 patients with DM, 68.3% and 58.4% were receiving any and moderate‐ to high‐intensity statin therapy, respectively. Patients receiving statin had higher burden of cardiovascular disease, were more likely to be on nonstatin lipid‐lowering therapy and to receive care at a teaching facility, and had more frequent primary‐care visits. Median facility‐level uses of any and at least moderate‐intensity statin therapy were 68.7% (interquartile range, 65.9%–70.8%) and 58.6% (interquartile range, 55.8%–61.4%), respectively. After adjusting for several patient‐related and some facility‐related characteristics, the median rate ratios for any and moderate‐ to high‐intensity statin therapy were 1.20 (95% confidence interval: 1.18‐1.22) and 1.29 (95% confidence interval: 1.24‐1.33) respectively, indicating 20% to 29% variation in statin use between 2 identical patients receiving care at 2 random facilities. Statin use was suboptimal in a national sample of patients with DM with modest facility‐level variation, likely indicating differences in statin‐prescribing patterns.

Comparison of Frequency of Cardiovascular Events and Mortality in Patients With Heart Failure Using Versus Not Using Cocaine

Beta-blocker treatment improves left ventricular function, morbidity, and survival in patients with systolic heart failure (HF). However, there are limited data addressing the safety and efficacy of β blockers in the setting of cocaine use as there is a perceived risk of adverse outcomes. Our aim was to determine if beta-blocker treatment was safe in HF patients with a history of cocaine use compared with HF patients without history of cocaine use. We also examined whether effects differed between cardioselective versus noncardioselective β blockers. Ninety systolic HF patients with cocaine use were compared with 177 patients with nonischemic, systolic HF, and no cocaine use. Outcomes were HF readmissions, major adverse cardiovascular events, and death using multivariable Cox proportional hazard models adjusted for age, black race, hypertension, diabetes, coronary artery disease, renal insufficiency, and angiotensin-converting enzyme inhibitors. Beta-blocker treatment in systolic HF patients with cocaine use did not have significant differences in HF readmissions (hazard ratio [HR] 0.66, 95% CI 0.31 to 0.1.38), major adverse cardiovascular events (HR 0.58, 95% CI 0.27 to 1.09), death (HR 0.96, 95% CI 0.39 to 2.34), or all combined outcomes (HR 0.76, 95% CI 0.39 to 1.47) compared with beta-blocker treatment in HF patients without cocaine use. Within HF patients with cocaine use, mortality rates (HR 1.50, 95% CI 0.28 to 8.23) were not significantly different between patients treated with noncardioselective versus cardioselective β blockers. In conclusion, beta-blocker treatment in systolic HF patients with cocaine use was not associated with adverse outcomes.

Premature Coronary Heart Disease in South Asians: Burden and Determinants

Purpose of ReviewWhile the burden of cardiovascular disease (CVD) is on the decline globally, it is on the rise among South Asians. South Asians are also believed to present early with coronary artery disease (CAD) compared with other ethnicities.Recent FindingsSouth Asians have demonstrated a higher burden of premature CAD (PCAD) compared with other ethnicities. These findings are not limited to non-immigrant South Asians but have also been found in immigrant South Asians settled around the world. In this article, we first discuss studies evaluating PCAD among South Asians residing in South Asia and among South Asian immigrants in other countries. We then discuss several traditional risk factors that could explain PCAD in South Asians (diabetes, hypertension, dietary factors, obesity) and lipoprotein-associated risk (low HDL-C levels, higher triglycerides, and elevated apolipoprotein B levels). We then discuss several emerging areas of research among South Asians including the role of dysfunctional HDL, elevated lipoprotein(a), genetics, and epigenetics. Although various risk markers and risk factors of CAD have been identified in South Asians, how they impact therapy is not well-known.SummaryPCAD is prevalent in the South Asian population. Large-scale studies are needed to identify how this information can be rationally utilized for early identification of risk among South Asians, and how currently available therapies can mitigate this increased risk.

Heart Failure, Introduction

Heart failure (HF) is a growing worldwide epidemic that results in significant morbidity and mortality in the aging population. HF is an important contributor to both the burden and cost of national healthcare expenditures, with more older Americans hospitalized for HF than for any other medical condition. Over the last two decades, there has been considerable progress in the treatment of HF with angiotensin-converting-enzyme (ACE) inhibitors, aldosterone antagonists, beta-receptor blockers, and resynchronization therapy. Nevertheless, HF is still associated with a poor prognosis. Approximately half of the people who develop HF die within 5 years of diagnosis. The search for better treatments for HF is one of the major challenges in cardiology. Greater understanding of the molecular dynamics and humoral perturbation will lead to newer HF treatment. In this chapter, different etiologies of HF, a systematic approach to the evaluation of a patient with HF, current strategies for the treatment, and emerging therapies in this field are discussed.